How did the WHO determine what women consider a positive birth experience? They asked midwives.

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In 2010 Thomas Balmes produced a delightful documentary entitled Babies following four babies through their first year, one each from San Francisco, Namibia, Japan and Mongolia.

The film shows that Baby Hattie from San Francisco had to be hospitalized after her home birth. Baby Bayarjargal, in contrast, was born in a Mongolian hospital. Why? Because his mother insisted on the filmmaker providing a hospital birth, which she otherwise could not afford, as the price of her participation.

The report uses the views of what midwives believe women want (unpublished, no less!) instead of the actual views of women.

I thought of that when I saw first saw the new World Health Organization recommendations Intrapartum care for a positive childbirth experience. How could the WHO determine what women consider a positive birth experience when there are such widely divergent views? Did they conduct focus groups? Did they consult the wide variety of literature on maternal satisfaction? Did they turn to mental health professionals for insights?

It turns out that they didn’t bother with any of that. They asked midwives instead.

The WHO published 56 recommendations and each one addresses a specific “intervention,” ranging from having a companion in labor to vitamin K injection for newborns. Each recommendation is accompanied by brief sections exploring women’s values and the acceptability of the intervention.

For example, in considering electronic fetal monitoring vs. intermittent auscultation, the authors note:

Values

Findings from a review of qualitative studies looking at what matters to women during intrapartum care (23) indicate that most women want a normal childbirth with good outcomes for mother and baby …

Acceptability

In a review of qualitative studies exploring women’s experiences of labour and childbirth, results suggest that women would prefer a more hands-on, woman- centred approach to care and are likely to favour any technique that allows for this  … (26).

Findings on health care professionals’ experiences of labour and childbirth from the same review (26), show that sta like to use a Doppler device because it offers reassurance and potentially leads to better outcomes for women (compared with CTG) (low confidence in the evidence). In certain settings, health care professionals prefer to use a Pinard fetal stethoscope because it facilitates a more woman- centred approach to care …

Compare that to the section of defining labor progress:

Values

Findings from a review of qualitative studies looking at what matters to women during intrapartum care (23) indicate that most women want a normal childbirth with good outcomes for mother and baby …

Acceptability

In a review of qualitative studies exploring health care professionals’ views of intrapartum care, with a separate sub-analysis of papers exploring staff attitudes towards the partograph (26), these studies … showed that health care professionals generally agreed that it was a useful way of monitoring labour progression …

Or the section on epidural use:

In a review of qualitative studies looking at what matters to women during intrapartum care (23), findings suggest that most women, especially those giving birth for the firate time, are apprehensive about childbirth … and in certain contexts and/or situations may welcome interventions that provide relief from pain …

Acceptability

In a qualitative systematic review exploring women’s experiences of epidural analgesia usage (126) there were mixed views. Views were influenced by the availability of epidural analgesia and by accounts of others …

Another qualitative systematic review on women’s and health care professionals’ experiences of labour and childbirth included health care professionals’ views on epidural analgesia (26) … The evidence suggests that some midwives feel that epidural analgesia is incongruous with the midwifery philosophy, and associate it with side-e ects, disconnection from the baby and the potential for further intervention…

Notice a certain similarity? Two references are cited repeatedly for nearly every recommendation in fact. In the 215 pages of the report reference 23 is cited 36 times and reference 26 is cited 81 times. These, along with reference 126 cited in connection with pain relief (19 times) are essentially the ONLY references for women’s views

What are these references?

23. Downe S, Finlayson K, Lawrie TA, Oladapo OT, Bonet M, Gülmezoglu AM. What matters to women during childbirth: a systematic qualitative review. PLoS One. 2018 (in press).

26. Downe S, Finlayson K, Thomson G, Hall-Moran V, Feeley C, Oladapo OT. WHO recommendations for interventions during labour and birth: qualitative evidence synthesis of the views and experiences of service users and providers. 2018 (unpublished).

126. Thomson G, Feeley C, Hall Moran V, Oladapo OT. Women’s experiences of pharmacological and non- pharmacological pain relief methods for childbirth: a review and qualitative comparative analysis. 2018 (unpublished).

Downe, Finlayson, Thomson and Oladapo are all members of the committee that put together the report.

Nearly every single determination of what women consider a positive birth experience relies on three unpublished papers, two by midwifery professor Soo Downe and one by midwifery professor Gill Thomson.

In yesterday’s post I was deeply suspicious of the claim that “Many women want a natural birth and prefer to rely on their bodies to give birth to their baby without the aid of medical intervention” when the reality is that many women, perhaps the majority of women, prefer to have pain relief, inductions, C-sections and all possible safety interventions.

I asked: Why do the WHO’s concerns map almost exactly to the concerns of midwives in industrialized countries?

Now we know why. The report uses the views of what midwives believe women want (unpublished, no less!) instead of the actual views of women. On that basis alone, the report is a farce.

Midwives want fewer interventions in childbirth, particularly interventions that they themselves cannot provide. Women want a wide variety of things, but most especially healthy babies and health mothers. There is no one-size-fits all recipe for a positive birth experience.

Sadly, this is yet another example of the way that midwives manipulate childbirth recommendations to suit themselves, women be damned.

  • Eater of Worlds

    Speaking of c-sections, apparently a bunch of hospitals in England have banned all c-sections that are not medically necessary. That is, no maternal choice c-sections are allowed. I just read so many stories of women damaged by that.

    • FormerPhysicist

      That’s hideous. Women should be able to choose.

      • LaMont

        Every single comment on any article about it is all “women are sluts who take the easy way out by choosing risky, dangerous, deadly surgery that takes forever to recover from”. It’s insane how evil and sexist the world is.

        • The Bofa on the Sofa

          What’s wrong with taking the easy way out?

          • sdsures

            Maybe vaginal birth-obsessed people think they have more/better bragging rights?

        • Nick Sanders

          If that’s the easy way out, what the hell is the hard way?

          • The Bofa on the Sofa

            Yeah, another case where they can’t keep their story straight.

            A “risky, dangerous, deadly surgery that takes forever to recover from” is the easy way out?

            Man, vaginal birth must be atrocious!

          • Empress of the Iguana People

            Well, it is argueably easier on the baby since she doesn’t have to get squished through Mom’s pelvis.

        • Petticoat Philosopher

          Arguments like that are actually pretty similar to turn-of-the-century arguments against both abortion and limiting family size, particularly as they were lodged against upper-class Anglo-Saxon women who were seen as having a duty to keep on breeding “desirable” children to out-compete all those Black and immigrant women. The arguments supposed that these women were just superficial bimbos who were too concerned about keeping their figures to do their womanly duty by the White Race. The idea of a woman actually making a reproductive choice based on what she was or wasn’t willing to put her body through filled many people with disdain. I guess it still does.

    • PeggySue

      I saw that. I believe it’s the Oxford University hospitals including the John Radcliffe. Pushed by midwives to some degree. The old “women are choosing this surgery because they are fearful about pain and need education.”

  • 3boyz

    Baby 1 was vaginal with an epidural, baby 2 was unmedicated, baby 3 was an emergency c-section. Given the choice, I’d go with option 1. But I’d actually take a c-section over unmedicated. While recovering from a c-section was painful and difficult, and it certainly was fun during the part where I feared for both the baby’s life and my own (I had a placental abruption), I STILL found my under-an-hour precipitous labor MORE traumatizing than the life-saving emergency c. People are always so shocked to hear that.

    There is constantly this messaging that a c-section is basically a tragedy and natural is “empowering” and it’s shocking to hear from someone who’s done both that actually, a c-section isn’t so terrible and “natural” is traumatic and not something I would ever choose again (though I may not have a choice. I was not in labor when my abruption happened, given my history, I assume that if I had gone into labor it would have been pretty quick, and there is a good chance that if I labor in future pregnancies it will be quick).

  • Allie

    Looking back on my experience, there are two things that would have made it more positive: first, I would have appreciated it if I had been offered pain relief options. At the time, I thought it was too late, as I was fully dilated when I arrived at hospital, but I later found out there were options I could have been offered while I pushed in agony for 5 hours. Second, I would have appreciated it if they had done a routine IV line when I arrived, so I didn’t have to writhe in agony with the nurse desperately trying to get the line in while the OB was up to his elbow trying to deal with my ruptured artery. They could have gotten the drugs in me a lot quicker. However, overall, I had an extremely positive outcome, so who cares about the experience? Oh right, WHO cares about the experience.

    • Merrie

      My first birth experience would have been more positive if I’d been encouraged to come to the hospital sooner and my providers hadn’t had the outlook like “try to stay at home as long as possible to avoid interventions”. With my second and third I went in when I thought I should, but with my first at the point that I thought I should go in, my midwife thought I should wait (after we talked by phone) and so I did. Traveling and going through triage and heplock placement at the point I was at was not fun. It would have been a lot less unpleasant if I’d done it earlier in my labor.

      With my third, I had de-converted from the woo and had recognized that a lot of people think epidurals are great and why try to go without one, but I was still torn about whether I wanted one or not. My experience would have been more positive if I’d been able to get my head straight about epidurals ahead of time rather than waffling. My labor was really short and I could have maybe had one, but ended up not, but I never felt really sold on the decision because I felt like trying to avoid an epidural was a pointless goal, and I kept second-guessing myself. I wish I’d been able to go into it with the outlook of “My labor probably won’t be that long and it probably won’t be worth the hassle (to me) to get the epidural, so I will continue to assume I will go without, and then if it ends up being more protracted than I thought, we’ll talk”.

      • Allie

        I was trying to follow the 5-1-1 or whatever (contractions 5 minutes apart, every on minute and lasting one minute, I think was supposed to be the criteria), but that just never happened. The contractions were all over the place. The only reason I called it when I did was we were running out of hot water for the shower. That’s when I told my husband “make the call”. I was part of a non-wooey birth program. The doc (general practitioner) came to my house, checked me, and immediately turned to my husband and said “get the car” : )

        • Merrie

          I don’t remember with the first–I just remember the contractions were really awful by the time we went in and I’d wanted to go two hours sooner. With the second one they said 10-1-1 since it wasn’t my first baby, but when I called at that point they said we could probably wait. We went in anyway since it was threatening to storm pretty soon and we didn’t want to be on the wrong side of it, and we were only there for a couple of hours before he was born. Then with the third one I woke up with contractions 2 minutes apart and we hoofed it to the hospital and called from the road.

        • sdsures

          How exactly does one “follow” bodily functions they have zero control over, like contractions?

          • Merrie

            I think she means that the providers told her to call when her contractions reached a certain frequency and length. That’s pretty common.

          • sdsures

            How is a labouring woman expected to monitor stuff like that herself? That’s what hospital equipment and staff are there to do.

          • Merrie

            You… time the contractions and the time between them? It’s not that hard. And you don’t have to time them exactly down to the second, but usually they’re looking for contractions at least a minute long and it’s not hard to tell the difference between a 30 second contraction and a 1 minute contraction or to tell if your contractions are 3 minutes apart versus 5 minutes or 10 minutes or if you’re just having an occasional random contraction. I used an app, but back in the days before smart phones a watch for timing contractions was pretty standard equipment for dad-to-be. You aren’t checking your own cervical dilation or the baby’s heartbeat. Just the amount of time that it hurts and then the amount of time before it starts hurting again.

          • sdsures

            Oh, okay. That’s reasonable. I thought initially that they were expecting patients (ie moms-to-be) to check their own cervixes or keep their eyes glued to the fetal heart rate monitor, “Call for a nurse if it dips below 90, dear.” Uhhhh!

  • namaste

    I have a twin niece and nephew, born in July. The day they were born all I could think of was that I was so relieved the pregnancy was over, and that everyone was safe and healthy. That, and obviously I was over the moon to meet them. How they were born was the furthest thing from my mind. All I cared about was that Katie was healthy and that I had two adorable new babies to spoil rotten and teach naughty sign language behind their mom’s back (Still a tad too young: I am biding my time). Well, okay, Katie’s epidural failed, and she was in a lot of pain. I would have preferred to see her spared that.

  • Anna

    Le Premier Cri is also a fascinating movie. Theres definitely a nachural nachure bent to it but it is balanced by showing that nachural nachure in actual nachural nachure often leads to nachural stillbirth. They follow an Indigenous woman – maybe Siberia?, a nomadic woman in North Africa, poor woman in India wondering how shes going to feed another girl, Vietnamese women in huge assembly line hospital, Japanese woman at woo-ey birth house, Canadian freebirth, French woman and a Brazilian woman I think wanting a dolphin birth (rolls eyes).

  • Anna

    WOW! I had my suspicions when I looked over the list of contributors and saw some big names from RCM and ACM there but I thought, surely they couldn’t influence a WHO study to that degree. Guess they can! I’ve also been noticing how Australian NCB midwives are using “feels” studies to try to advance their agenda and here they are getting away with it at a global level. I wonder how they collected the data for those studies. Did they advertise the surveys on NCB groups on FB I wonder? Theres a few of us Homebirth Loss Mums that have been filling in every survey they ask for responses for on NCB groups and we’re waiting to see if our reponses are ignored or passed off as “insignificant”. We also particularly love our babies deaths being referred to as “unfortunate outcomes”. So “with woman” – so feminism!

  • Casual Verbosity

    Even if proper studies were conducted on what women want in childbirth, I would be concerned about the effect of social desirability bias. Since women are constantly told how much they should want natural childbirth, even if they want every intervention under the sun, they may find it difficult to put that to paper. And no doubt, even if proper studies did show that the majority of women wanted certain interventions, the research would likely be conducted by midwives anyway, so they’d spin it into: “Mothers Need More Education on the Superiority of Natural Birth”.

    • Anna

      Very true. And many women that have not experienced an unmedicated “normal” birth may think thats what they want until they get there. I remember thinking in labour, “now why was it I wanted to do this?”. Women may place great value on physiological birth because they dont know there are risks, while c-sections, inductions, epidurals are roundly criticised with a list of scary sounding risks a mile long. And also bingo to you – if a woman says she doesnt care about the birth experience or having interventions as warranted it must be because shes “conditioned by the patriarchy”.

      • out of the loop

        Why is everyone suddenly calling vaginal birth “physiological birth”?

        • Casual Verbosity

          Because they don’t like the word “vaginal”? No idea. I feel like “physiological” has nicer connotations than “vaginal”, so maybe it’s a euphemism. Just a hint though; if the thing you’re trying to sell needs a euphemism, then it’s definitely not as lovely as you’re making it out to be.

          • Juana

            “Physiological” also precludes many interventions if taken literally. A caesarean is obviously neither physiological nor vaginal, but vacuum or forceps assistance aren’t physiological either. So the connotation is not only nicer, but also stricter. Win-win.

        • The Bofa on the Sofa

          Naturalistic fallacy

        • Anna

          Because vaginal isn’t “nacheral” if you had an induction, epidural, ctg monitoring, an IV, instrumental delivery or any other interventions. Its important for NCB midwives to distinguish between no intervention = good and intervention = bad. Problem is women keep giving the feedback that the use of the words “normal” and “natural” are upsetting for women because it suggests “abnormal” or “unnatural” if you did have intervention and no-one really likes their baby and/or their experience being referred to as “abnormal”. UK midwives and their copycats in Australia refuse to back down on this so they’ve gone to using the word physiological. Just so those failures that had inductions or epidurals or whatever know they didn’t really have a “proper” birth.

          • in the loop, now

            Thanks to you and to everyone else who answered. I think I went my entire life without hearing that phrase, but lately it’s been everywhere!

  • swbarnes2

    Shouldn’t an “in press” article be available to read? I can’t find that first one.

    • crazy mama, PhD

      “In press” usually means that the article has been accepted for publication but hasn’t actually been published yet.

  • MaineJen

    “The evidence suggests that some midwives feel that epidural analgesia is incongruous with the midwifery philosophy, and associate it with side-e ects, disconnection from the baby and the potential for further intervention…”

    ‘Why MaineJen did not want midwife-led care while giving birth,’ exhibit A.

    • StephanieA

      I seriously don’t get this AT ALL, considering the women I take care of who don’t want to hold their babies are always the ones who had no pain relief, because they’re in shock/too much pain. It has to be plain misogyny.

      • guest

        This is my personal experience as well. My first was unmedicated and I was in no mood to hold him for a while. My 2nd with an epidural I was fully present for and held her the whole time I was being stitched up/checked over. Being fully present for the experience was my main reason for the epidural. With my first, most of the labor/delivery/right after is a total haze because all I was focused on was the pain.

  • AnotherOor

    How did midwives get elected to speak for all women?

  • Jessica Cupit

    This is dismaying.

  • mjd3

    sort of off-topic: is anyone else a fan of Crazy Ex Girlfriend? Paula’s ode to childbirth in the season finale was HILARIOUS.

  • crazy mama, PhD

    Can I just say how much I love Babies (the film)? I thought it did a beautiful job of showing cultural differences without romanticizing anything. We see the Namibian mothers casually breastfeeding multiple children, but also the dirt and flies that come with living in a rural hut.

    I didn’t realize that the San Francisco baby was a home birth, though—the filmmakers conveniently cut that out and start with her hooked up to a bunch of machines at the hospital. (I’d assumed she was premature.)

    • Kelly

      They had an article that interviewed the parents a few years after the film. The mom of that home birth baby said that they were glad she was born in a calm home birth and that the three days spent in the NICU afterwards getting antibiotics and help breathing were no big deal. Really, any NICU time to me would be a big deal at the time.

      • crazy mama, PhD

        My brain is overheating right now trying to understand how they could prioritize the exact moment of their baby’s birth over the first few days of her life. Do they even hear themselves?

        • Kelly

          They have to make themselves feel better about their decision that landed their daughter in the NICU for three days. I wish they could just be honest and say that she made a mistake. One of the other mothers had the producers pay for her hospital birth because it was safer and she did not have the money for it.

  • Empress of the Iguana People

    To appropriate their terminology, cesarians are a variation of normal birth. After all, being a lefty is a normal variation and there are at least as many cesarians in wealthy countries as there are lefties.

  • fiftyfifty1

    It dismays me how apparently easy it is for special interests to hijack supposedly science-based policy recommendations.