“One of the most disappointing and deeply worrying themes that has emerged is the reported lack of kindness and compassion from some members of the maternity team.”
This is perhaps the most disquieting sentence to be found in the first report into failures at the maternity services at the Shrewsbury and Telford NHS Trust between 2000 and 2019, published last week. The report is critical of many of the practitioners involved in delivering maternity care, but it is the Trust’s midwives that are criticised most of all.
This profession, usually associated so strongly with “kindness and compassion”, is here associated instead with cruelty and tragedy: 13 women dead in childbirth, hundreds of babies dead, and many more left disabled after traumatic births. Speaking to MPs on the Commons Health Select Committee, Donna Ockenden, who is leading the independent investigation, described a legacy of “broken families and women who carry guilt on their shoulders for many many years”.
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It seems now that many of these tragedies were a consequence of a dogmatic opposition to performing c-sections. While the national c-section rate averages 24% to 29%, at the Shrewsbury and Telford Trust it was between 8% and 12%, apparently due to a widespread belief among midwives that a low rate was a sign of good maternity care.
In fact the opposite proved true, since the report concludes that in many cases earlier recourse to c-section would have avoided death and injury. And some midwives’ single-minded quest for natural (i.e. vaginal) births at “almost any cost” was often achieved through unnatural means, including the injudicious use of forceps and hormonal induction, causing additional harm. Worst of all, when babies died during these protracted and agonising deliveries, patients’ pleas for c-section having been ignored, some of these grief-stricken women were then told that they themselves were to blame for the disaster.
When news of this scandal broke, my Twitter feed was immediately filled with women recounting their own experiences of bad care at other NHS Trusts. Most mothers have some sort of horror story to tell — either their own, or that of a friend or family member — and most of these stories include some kind of error on the part of a medical professional. Usually these involve a lack of intervention, or an intervention of the wrong kind, and women almost always report a feeling of not being listened to or cared for — of being treated like rag dolls, passive and mute.
I’m now 18 weeks pregnant with my first child, and I’m in the unusual position of knowing that I will be having a planned c-section for medical reasons. There’s no debate to be had about how the birth will go — I know exactly what’s in store for me come May. And am unlikely to experience the subtle or not-so-subtle pressure often put on pregnant women to stick as closely as possible to the natural childbirth ideal.
Of course, some women are enthusiasts for natural childbirth, and personally fare well by it. But it’s important to recognise that there is a heavy dose of ideology at play here. A woman I used to work with was evangelical about homebirthing, despite the fact that both of her babies had been rushed to hospital in ambulances when their births went wrong. But when telling her birth stories she would include that detail only in passing, focusing instead on the “energy” and “joy” of the experience. The natural approach all too often requires its adherents to gloss over pain, injury, and danger, repeating again and again “pregnancy is not an illness” (then why do I feel so ill?).
There is a reason why the God of the Old Testament punished Eve by condemning her to bring forth children “in sorrow.” The writers of Genesis were no fools — they knew what childbirth was like, and no amount of New Age woo can ever quite conceal an ancient truth: that while this form of human experience may be wonderful, it is also terrible, and even in the modern world still carries with it the stench of death.
The immense importance of childbirth means that power over it has always been contested, just as it is today. When the ‘man-midwife’ first emerged in the 18th century, this progenitor to the obstetrician was viewed with hostility by the female midwives who traditionally had sole control over the birthing chamber. For a period, the fashionable choice for wealthy British women was to employ a man to attend the birth, and he would arrive in a smart coat and carrying a bag containing the latest in medical technology: a pair of forceps. Poor or unfashionable women continued to rely on their local midwife, until gradually childbirth became more and more medicalised and power over this female domain was passed to male hands.
This centuries-old rivalry between midwives and obstetricians still persists, despite the fact that UK medical graduates are now majority female. Conflict may have been particularly acute at the Shrewsbury and Telford Trust, but it was far from unique. Doctors stereotype midwives as vain ideologues who put women through hell for the sake of their egos (“sadists” is the word used by one of my doctor friends). In turn, midwives condemn doctors as arrogant brutes who see a scalpel as the solution to the slightest complication.
There is some truth to both of these perspectives. A remarkable episode in the third season of Mad Men provides a graphically accurate illustration of the over-medicalisation of hospital births in the 20th century. Betty Draper is shaved, sedated, given an enema, and has her legs placed in stirrups, a birth position that provides better visibility to practitioners, but forces the labouring woman to work against gravity. Frightened and isolated, Betty sobs for mercy and goes uncomforted. We’ve since made progress, but this sort of once typical hospital experience couldn’t be further from the ‘woman-centred care’ that the midwifery profession tries to promote.
Nor do hospital births have an unblemished safety record. Igaz Semmelweis, surely one of the most tragic figures in the history of medicine, realised in 1847 that the high maternal mortality rate in his Viennese hospital was an accidental consequence of doctors’ physical contact with women in labour. Ignorant of germs, doctors would go straight from the dissection lab to the maternity ward without washing their hands, bringing deadly infections with them.
The desperate Semmelweiss tried to alert his peers to the harm they were inadvertently committing and found himself ostracised. He suffered a nervous breakdown, was admitted to an asylum by his colleagues, and died shortly afterwards, with the truth of his theory still unacknowledged. More than 20 years later, Louis Pasteur finally convinced the medical community to accept germ theory and wash their hands before examining patients. We have no way of knowing how many mothers died needlessly in the interim.
Yes this is history, but my point is that sometimes doctors make things worse, and sometimes midwives do the same. Errors made by both ‘sides’ have been used down the ages to bolster the case for either natural or medicalised childbirth, with feminists generally taking the midwives’ side. Classic second wave texts like Witches, Midwives, and Nurses present a highly politicised historical narrative of feminine knowledge wrested from women by men envious of the power of the female body.
Some proponents of the natural approach are so resentful of this male incursion that they go further even than homebirthing and choose to ‘freebirth’, with no medical assistance at all. With lockdown restrictions limiting access to NHS midwives at home, more women are opting to freebirth illegally, with some reported to social services as a result.
Maybe it’s because I wrote my Master’s dissertation on the grisly history of childbirth, or maybe it’s because I did part of a medical degree and so have some bias towards the doctors’ ‘side’ of the debate, but I’m afraid I can’t see freebirthing as anything other than stupidly reckless. But then again, I do understand the fear women have of giving birth in hospital without their loved ones, as nearly 2,500 women have been forced to since the start of October. The feminist writer and campaigner Caroline Criado Perez has written about her own awful experience of miscarrying in hospital without her partner present. Lockdown adds a new form of suffering to an experience already replete with it.
The Covid ban on visitors during childbirth is inhumane
It does remain thoroughly baffling that the suffering remains, and that the pace of development for obstetric technology is so oddly slow. The maternity team at the Shrewsbury and Telford Trust have been criticised for misusing an implement that has hardly improved in several hundred years: forceps. There is still no good form of pain relief available in labour, it is still common for women to suffer tearing, prolapse, and incontinence and, even in the West, women and babies still die far too often, particularly black women. Our species has been to the moon and built nuclear weapons, but we haven’t yet managed to remove agony and risk from one of life’s shortest journeys.
The mistakes made at the Shrewsbury and Telford Trust show us what happens when the ‘natural’ is fetishised. But, at the same time, we can’t avoid confronting the fact that medicalised childbirth is hardly much better. The Trust’s midwives were not wrong to consider c-section an undesirable option, given that surgery and recovery carry their own harms and risks. What they were wrong about was to assume that denying patients a c-section was a better option.
There are no desirable options when it comes to childbirth, only relatively worse ones, and there is no way through it without pain. I do realise that this isn’t an easy problem to solve. Childbirth is worse for us than it is for other animals because of the trade-off that Genesis describes in metaphor: we stood up to free our hands, and we developed large brains, and in doing so we narrowed the pelvis and enlarged the infant head.
But I look at what happened when the entire world was focused on just one medical problem — producing a vaccine for Covid-19 — and the astonishing speed with which a solution was found. And then I look at what happened at the Shrewsbury and Telford Trust, where patients were denied access to a routine form of lifesaving treatment. Not only do advances in obstetrics lag behind other areas of medicine, it’s also the case that, even when the technology does exist to reduce injury and suffering, it often goes unused, and without even the cheap and simple application of “kindness and compassion” to soften the blow.
A GP that once mentored me used to tell her anxious patients at the antenatal clinic “it’s only one day of your life,” and I thought at the time that a prisoner in fear of the torture chamber would hardly be comforted by such a statement. In our safe and affluent society, we don’t usually tolerate pain and danger, but we do in this case, and the nature of the burden means that it is only women who are asked to bear it. Can that be a coincidence?