Are We Getting Birth Right?

By: Malisha Kumaranathunga

“A few hundred years ago, there were no doctors and nurses to assist childbirth. There was a lady in the village with experience, although uneducated, who would conduct the delivery,” says Professor M. Sathanandan, Obstetrician and Gynaecologist, reflecting on birthing practices prior to its institutionalisation. “During that process there was human wastage, where about one in ten mothers, and one in four babies, would die.”

Professor Sathanandan felt societal expectations had transformed significantly, and that maternal and infant death was no longer acceptable. “We want comfortable labour for the mother, without any damage to her perineum, which could lead to permanent difficulty having sex. Similarly, we want a perfect child, with no physical or mental abnormalities. This change in human expectations is important to consider as this helps us understand what has led to the medicalisation of birth.”

Sri Lanka has been applauded as the beacon for maternal healthcare in the region, boasting one of the lowest maternal mortality rates (MMR) in South Asia at 29.2 maternal deaths per 100,000 live births. Much of this success has been attributed to the medicalisation of childbirth, with 99.5% of births taking place in hospitals; 94% in government sector hospitals and 5% opting for private healthcare. “The average age of a woman becoming pregnant is increasing in Sri Lanka, especially due to women entering the workforce,” says Dr. Y. Manikkage. “Advanced age of the mother automatically makes the pregnancy high-risk and requiring more medical support. Continuous medical care in such a situation, or any pregnancy, is beneficial since it would help in identifying complications early and managing them.”

However, concerns have been raised about the overuse of medical interventions, such as episiotomies, where the tissue between a woman’s vaginal opening and anus is cut during childbirth, caesarean sections, where a baby is extracted from the mother by cutting through her abdominal wall and uterus, as well as the administering of synthetic oxytocin to augment labour. Medical interventions tend to necessitate more interventions, resulting in an issue referred to as a “cascade of interventions” that may have negative consequences for both mother and fetus. “This does not mean medical interventions are unnecessary,” says Dr Manikkage. “Each case should be evaluated individually, and appropriate medical interventions should be used where needed.”   

Birth Abuse and Obstetric Violence

In the government sector, family health midwives form the backbone of maternal healthcare and are the primary birth attendants responsible for the labouring women in their wards, and therefore, have a significant impact on the birth experiences of mothers. Although midwives have been praised as highly successful in keeping the mothers and infants in their care alive, they have also been criticised for being patronising, impatient, disengaged, and incompetent, especially when considering the mental and emotional wellbeing of mothers. There is a new term formulated for the mistreatment of women by maternal health care providers; obstetric violence. The World Health Organization (WHO) classifies obstetric violence as any abuse, disrespect, mistreatment, or violation of a woman’s dignity during childbirth.

Obstetric violence can range from verbal and physical abuse, neglect that results in avoidable complications, over-medicalisation and non-medically justified obstetric interventions. A recent study in Colombo found that obstetric violence is prevalent in government sector maternal healthcare facilities, with mistreatment more likely when the woman is of a young age, with lower family income, belonging to an ethnic minority and/or living in a rural area. 18.1% of the 1375 women who participated in the study affirmed that they had experienced obstetric violence at the hands of healthcare providers, with the majority exposed to emotional violence in the form of verbal abuse, insults, and neglect. Some also experienced physical violence such as hitting, slapping, and pushing, as well as sexual abuse.

Research shows that obstetric violence is neither reported to legal and institutional authorities nor discussed by women within their informal social support networks. There is evidently a social stigma surrounding childbirth. “Women go to the hospital and come back with a baby, and what happens in the intervening day or two remains a somewhat terrifying mystery,” says Milli Hill, in her book, ‘Give Birth Like a Feminist: Your body, your baby, your choices.’  “We’ve become blinkered to the massive imbalance of power in the birth room, and somehow come to accept that birth is inherently unpleasant and undignified, or even traumatic, degrading and violating.”

It is imperative that birth is demystified, so that we can ensure that maternal healthcare adequately fulfils the physical and emotional needs of mothers. As many as 25 to 30 women in Sri Lanka commit suicide each year, during pregnancy or within a year of giving birth. Women are conditioned to believe that their birth expectations should be limited to a healthy baby, but many experience feelings of trauma, sadness, shame, powerlessness, and violation during childbirth that significantly impact their emotional and mental wellbeing, as well as their relationships with their partner and children. Therefore, there is a strong case for improving our understanding of childbirth, raising awareness about birth trauma, and the significant implications on health services and clinical practices.

Medical Paternalism: Doctor knows best?

“Modern scientists agree that the most dangerous path a human being ever takes is its passage through the birth canal. In no other circumstance would we voluntarily take a dangerous path like vaginal delivery,” says Professor Sathanandan. “This is because, during vaginal delivery, as the baby moves through the birth canal, it gets squeezed, and blood supply to the brain gets cut off intermittently during that period. This can lead to mental derangement.” Modern obstetric practices are based on the perception that physiological birth is inherently dangerous. Thus, current birth practices are rife with medical interventions, raising concerns that obstetric healthcare providers follow a “too much, too soon” approach during childbirth.

It is well documented that maternity care across the globe is informed by professional and organisational cultures rather than the best available evidence. This is particularly evident in the stark variations in medical interventions such as episiotomies and caesarean sections both within and amongst countries. It was determined, as far back as 2009, that episiotomies, where the vaginal opening is cut to widen the and passage and help facilitate birth, should not be used as a routine procedure as it led to adverse outcomes for women, such as a higher risk of perineal tearing, the increased need for suturing and re-suturing, as well as healing complications such as haematomas. Nevertheless, it is a common practice that women, especially first-time mothers, be given routine episiotomies during vaginal deliveries.

Episiotomy rates vary widely between countries. The WHO recommends an episiotomy rate of 10% for all vaginal deliveries. In countries such as Denmark, Sweden and Iceland, episiotomy rates range between 5-7% whereas the rates are as high as 80-90% in Latin American countries. A 2013 study in Sri Lanka found that episiotomy rates at the Anuradhapura Teaching Hospital and the Castle Street Hospital for Women were 59% and 96.5% respectively, which is far above the recommended rate.

The overuse of medical interventions is also true of the caesarean section procedure. While there is some uncertainty about the optimal C-section rate for a nation, it is recommended that the rate remain under 20%. As with episiotomy rates, C-section rates vary significantly between countries, with low rates of 15% in the Netherlands and Israel, and very high rates of 45-50% in countries like Turkey, Mexico and Chile. In Sri Lanka, the C-section rate was recorded at 40.8% in 2018, and is predicted to increase to 49.2% by 2025.   

C-section deliveries should be discouraged as they are costly, have a higher a risk of maternal and fetal complications, and require longer hospital stays. C-sections also pose greater health risks when compared with a vaginal delivery, such as a higher incidence of postpartum haemorrhage, increased occurrence of chronic abdominal pain, as well as wound complications and risk of infection. Therefore, it is imperative that we change perceptions of C-section deliveries being as safe as vaginal deliveries, which may help reduce the level of elective caesarean rates in the country.

The Shy Hormone: The influence of oxytocin on birth  

Like all birthing mammals, women also require a certain environment to effectively give birth; an environment that is dark, cosy, and undisturbed. Therefore, it is not surprising that, in crowded, brightly lit obstetric units with multiple people observing birth, women’s labours tend to stall and require medical intervention. Human birth is reliant on a complex interplay of hormones, the key player being oxytocin. Coined as “the love hormone” because oxytocin is released when human beings fall in love, have sex and orgasm, it is also referred to as “the shy hormone” because it prefers settings that would typically be considered romantic, i.e., softly lit, quiet, soothing, and safe. Without the right environment, labouring women would not produce enough oxytocin naturally, which may result in their labour stalling.

Synthetic oxytocin (known as Syntocinon) is one of the most common medical interventions used to facilitate the progress of labour and birth. It is administered to induce labour where a woman has gone past her due date, or when her labour stalls during childbirth. Syntocinon works differently in the body compared to oxytocin that is naturally produced, and it can have unpredictable effects, such as interfering with the attachment and bonding of mother and child, as well as having negative impacts on breastfeeding. It should, therefore, be alarming that oxytocin infusions are commonly used in Sri Lankan labour wards for the majority of women in labour.

A review article on the use of oxytocin for labour induction in the Sri Lanka Journal of Obstetrics and Gynaecology states, “Synthetic oxytocin is widely used. However, its use has not been standardised, and there are allegations of it not being used properly and even abused at times. If used incorrectly, it can become a very dangerous medication, with serious adverse consequences to the mother and her fetus. Although endogenous (natural) oxytocin has additional, beneficial effects on the brain, these benefits are absent with exogenous (synthetic) oxytocin infusions.”  

Syntocinon also creates more frequent, longer, and stronger contractions, and therefore, significantly increases pain sensations during labour. This can negatively impact the fetus, resulting in abnormal fetal heart rate patterns, and fetal distress, which in turn, increases the likelihood of the woman having to undergo an emergency C-section. Women who are administered Syntocinon in other parts of the world are routinely given epidurals, a form of pain relief, to counter the increased pain sensations. Unfortunately, this form of pain relief is not available to labouring women in government sector hospitals as anaesthetists are not readily available in the wards.

Birthing Against Gravity – The lithotomy position

The seventeenth century French doctor Francois Mauriceau is credited for encouraging women to birth laying on their back. Mauriceau, a product of his time, defined all births as pathologic and abnormal, claiming that pregnancy should be properly construed as a “tumour of the belly.” Some scholars also claim that the lithotomy position was a perverse desire of  Mauriceau’s contemporary, King Louis XIV of France, who felt sexual arousal watching women give birth, and was frustrated by the obscured view of popular birthing positions of the time, such as kneeling, squatting or standing.

Pioneer birth scene illustration showing woman, husband, midwife and two attendants.

Although the adoption of the lithotomy position is not based on sound scientific evidence, and rarely observed by indigenous cultures or in antiquity, it is now the standard and mandated position in which women are expected to give birth. “It may not be the most comfortable position, but it is the optimum position because when the woman keeps her legs up and wide, it is easy for me to examine her vaginally,” says Professor Sathanandan. “Squatting or kneeling prevents intervention by the midwife if there is a necessity. If you are not on the bed, the midwife can’t use the CTG machine to monitor the baby’s heart. Amongst healthcare personnel, their objective is to get the best outcome for the baby and mother, not what the mother likes. Because the most important thing is to have a healthy baby at hand, and a healthy mother at the end. The rest is secondary.”

The lithotomy position is convenient for healthcare providers as it is the optimal position to observe the birth, use medical instruments such as forceps or ventouse (suction), and perform suturing, where required. However, it is far from optimal for birthing women, narrowing their pelvic outlet, and requiring them to push their babies upwards and against gravity. In such circumstances, it is no surprise that women need to be cut open to give birth.

Birth Revolution: The demand for natural birth

Taking all these factors into consideration, the benefits of modern obstetric practices have come at a significant cost to mothers, resulting in women forced into uncomfortable birthing positions, enduring artificially augmented labour that is more painful (without the right to pain relief in public healthcare), and with a high likelihood of major abdominal surgery. Thus, it is no surprise that there has been a significant uptick in the demand for C-sections amongst women with the economic means to do.

It may be shocking for some to hear that an unmedicated or “natural” birth has become an anomaly in modern obstetrics. “In our current culture, a normal, straightforward, physiological birth is one of the hardest types of birth to come by, becomes rarer by the day, and is currently in danger of total extinction,” says Milli Hill. Modern obstetric practices are designed to monitor and control childbirth to achieve the best health outcomes for mother and child. However, evidently, much has been lost in the process.

The time has come to challenge the needs of healthcare providers as paramount, and those of labouring women as an afterthought. This is especially true regarding the birth room, where currently the basics of female physiology have been ignored. Milli Hill explains this succinctly, “Bright lights so the birth attendants can see, beds so the birth attendants can reach, open doors so the birth attendants can come and go as they please – all of these standard elements of the birth room architecture centre the care provider over the production of oxytocin, in spite of the mechanics of this hormone being so obvious and so basic.”

Positive Birth Experiences: The role of labour companions

Natural and positive birth requires an environment where the labouring woman feels confident, safe, and unafraid. This can be facilitated through educational resources and prenatal classes that prepare women for birth along with the presence of a trusted labour companion during childbirth. “I do believe that is very much a part of how we achieve comfortable and peaceful births that women look back on with joy,” says Serena Burgess, a certified non-medical birth companion (also known as a doula) and prenatal yoga teacher. Serena talks about the importance of a woman participating in the decision-making process during her labour, “A lot of women feel disenfranchised by their birth experience and that is what leads them to feel dissatisfied with their births.” Doulas play a vital role by providing much needed physical and emotional support to mothers in the lead up to, and during, their labour.

Research has shown that when women are allowed a labour companion, it improves maternal satisfaction, reduces the need for labour augmentation, and helps facilitate breastfeeding after birth. “To prevent pain, the most important thing is vocal anaesthesia. The woman needs a caring assistant by her side, who will keep talking to the mother, reassuring her, and explaining to her what is happening. That is the best painkiller.” Says Professor Sathandanan. “Midwives don’t have the time to give one-to-one to each lady in their wards. Therefore, it is important for a woman to have a labour companion, who is educated on the birth process and has experience in it, at her side.”

Although Sri Lanka made a policy decision as far back as 2011 to allow women a labour companion, this guideline has not been satisfactorily implemented. A 2017 study found that the majority of obstetricians did not allow labour companions in their wards, and lacked awareness of the advantages of the practice, such as shorter labour, less need for pain relief, higher incidence of vaginal birth, and improved neonatal outcomes. In a study conducted at the De Soysa Hospital for Women, the largest maternity unit in Sri Lanka, only 9.5% of women reported having a labour companion during childbirth.

A Humanised Model of Maternal Healthcare

Maternal healthcare needs an overhaul: it needs to be reframed with the physical, emotional, and mental wellbeing of the mother at the centre of decision-making. Hospitals and clinics can improve birth experiences by understanding and catering to women’s physiology to facilitate positive birth outcomes. “It’s really important that the environment we create for labouring women is calm, and doesn’t feel scary or dangerous,” says Serena, “The birth room should be pleasant and unintimidating, and the woman should feel that she is in control.”

Serena also talks about how change requires work by women themselves. “Women need to educate themselves so that they know the right questions to ask and have an understanding of what the doctor means when something is being discussed, and what the repercussions of that action would be so that they can ask if it is really necessary, and what alternatives are available,” says Serena. “It’s important for women to understand why a medical intervention or procedure is necessary in their case, and it helps them cope with their labour.”

Positive birth experiences are achievable with the right education and preparation. It requires a shift in societal attitudes where childbirth is understood as a natural and physiological process where women can be confident, empowered, and active participants in their labour, an experience that they would cherish for the rest of their lives.  

About:

The thoughts expressed in this article are the writer’s own, and do not represent medical advice. The writer has a Master’s degree in Gender & Women’s Studies from the University of Colombo. Her work aims to highlight key feminist concerns and opportunities for reform. She can be reached at: [email protected]