By Caroline Flint

The importance for a woman to be in control of her own childbearing

For most women becoming a mother is the most important and most powerful role that she will ever take on. To a small child his mother is like a goddess - she is the source of all knowledge, the source of all nourishment, the source of all power, the source of all self esteem. To the small child and infant, the mother is a marvellous, exciting, amazing person, the source of delight and love.

To take on this very powerful and demanding role it is obvious that a woman needs to be brimming over with self confidence, she needs to feel strong both physically and emotionally, she needs to feel in control of the situation.

When examined closely, the way in which we provide care for pregnant women at the present time actually puts the woman at an enormous disadvantage when taking on the role of being a mother. It is almost as if we had designed a regime which makes women feel powerless and overwhelmed - at a time when they need to feel more powerful than at any time in their lives.

Maternity care is provided to woman in alien surroundings, at times which are convenient to us, and often inconvenient for them, in hospitals which for most people represent illness, pain and death. At every stage of this tender sequence we surround her with strangers.

When labour starts the woman leaves the warmth and familiarity of her home, her own place which smells of her, feels like hers and is hers and she travels to the hospital, to be greeted by a midwife she has never met before, who ushers her into a room - the like of which she has no experience.

Perhaps it is time for us to look again at what we now regard as the normal way of having a baby, and think about how it would or could be for the women if they were in a powerful position during their pregnancy and labour.

The woman is totally in control of the situation when she employs her own independent midwife to deliver her in her own home - and when examining this model several factors come up in that pattern of care which are worth thinking through.

When a woman engages an independent midwife the midwife comes to the woman's home, on the first visit it is to be `looked over'. The woman may not take to her and may not engage her. All this is the woman's decisions, she is the employer and the midwife is a visitor in her house. The relationship starts from this basis - that the woman is the hostess and the employer, she is in charge.

The midwife will practice her profession to the best of her ability and will advise as necessary, but the bottom line is that the woman can either take or reject that advice - the midwife must continue with her care (United Kingdom Central Council for Nursing, Midwifery and Health Visiting, 1986), at the same time informing the Supervisor of Midwifery. At all times it is the woman's decision which counts - the woman holds the position of power.

Antenatal consultations will normally be held in the woman's home at a time which is convenient for her and her partner. She may be seen in the evening when her partner is available or during the day or at the weekend. She will have notes which are seen as a diary of pregnancy, labour and puerperium to be written in by the midwife, the man and the woman - there will be space specifically for the couple to chronicle the progress of their pregnancy. At the end of the postnatal visits at 28 days the woman will be given a photocopy of her notes to keep as a record of this pregnancy and labour.

When the woman is in control of her labour she telephones the midwife when she thinks she is in labour, they arrange when the midwife will come to the house. During the labour the woman takes up whatever position she wants and most women are extremely active, roaming around the house or the flat, often rocking and rotating their pelvis quite instinctively and thus changing and enlarging the pelvic diameters (Dunn, 1976; Russell, 1982). The woman is surrounded by furniture which she has brought specifically for her comfort, bean bags or a leather sofa or plain wooden chairs - the variety of homes is only equalled by the number of people who live in them - the place of labour is a place which she has designed for herself and her partner's needs -it is totally unique, there is no other place the same.

Equally, what the woman chooses to eat and drink during labour will be unique, she will have the sort of foods she likes and

it can vary between crackle and pop cereal, to fruit spreads on bread, to macaroni pie, to soups, fruit teas, honey or tea and a biscuit. She is in charge of what she eats - she is in control of this aspect of her labour as she is with all other aspects of her labour.

The other factor of labouring in her own home surrounded by people she knows and trusts is that she can feel completely uninhibited either when she wants to make a noise or if she wants to remove her clothes, she can be in the bath, leaning against the worktop in the kitchen, or sitting on a sofa in front of the television having a cigarette (no place here for `allowing' or not `allowing') and watching the racing - it is her choice, she is in charge.

Our home is a place of sanctuary, total privacy is assured, no one comes in without an invitation, anyone who might disturb the peacefulness or the atmosphere of the labour is excluded.

After the delivery other factors increase the woman's self confidence. A few hours after the delivery the midwife leaves, she will have the instructed the woman and her partner into the intricacies of nappy changing and the baby will have suckled at the breast shortly after the delivery, but as she leaves the baby is left in the care of its parents and they manage. Many women stay awake following the birth gazing at their new baby, listening to every respiration, aware of every grunt and squeak, when the baby appears hungry the woman puts it to the breast and she manages.

From the very start the woman is this baby's mother and she learns to care for him or her. The woman learns that she has strong maternal instincts, learns that this baby is unique and she needs to learn how this baby ticks in the same way the baby is learning how to suck at these breasts, all this helps to increase the woman's perception of her own power and abilities.

If our concept of normality stemmed from this model - a woman in control of her own pregnancy consultations, labour and postnatal period, eating and drinking those foods she finds palatable, wearing or not wearing what she likes, surrounded by comfortable and familiar furniture - but above all assured of total privacy and attended by a midwife she has been able to get to know well for whom she is the employer, I suggest that our care even in hospital would change dramatically, and that it might keep pace with women's demands - they after all are the people who pay our salaries, who keep the National Health Service afloat with their taxes and who ultimately are our employer. The time has come to encourage more women to have their babies at home - with a baseline of powerful women giving birth in their own surroundings - all those involved in childbirth would have a new baseline, a baseline of true `normality' on which to base their care. The time has come - as is reflected on the following quotations;

`A recognized home confinement service should exist in all health authorities.' (Royal College of Midwives, 1987).

`Forms of care which should be abandoned in the light of the available evidence - Insisting on universal institutional confinement'. (Enkin et al., 1989).

`The recent results of maternity care in Holland reliably confirm what might have been surmised from the earlier results there - that midwives, practising their skills in human relations and without sophisticated technological aids, are the most effective guardians of childbirth and that the emotional security of a familiar setting, the home, makes a greater contribution to safety than does the equipment in hospital to facilitate obstetric interventions in cases of emergency.' Jew, 1989).

`Mothers are also nowadays almost always offered the option to give birth at home so long as there is sound medical advice to support that in each case.' (Clarke, 1989).

`Mrs Virginia Bottomly Health Minster opened the Conference - her message to the midwives was that their human and psychological skills must be used, and that women must have choice between giving birth at home, in a GP unit or in a hospital. (Bottomley, 1990.)

`It has never been scientifically proved that the hospital is a safer place than the home for a woman who has an uncomplicated pregnancy to have her baby. Studies of planned home births in developed countries with women who have had uncomplicated pregnancies have shown sickness and death rates for mother and baby equal or better than hospital birth statistics for women with uncomplicated pregnancies.'

(World Health Organization, 1985).

`The main findings in this survey of all births occurring at home in England and Wales in 1979 were the low perinatal mortality among births booked to occur at home and the considerably higher mortality among births booked for hospital or not booked at all.' (Campbell et al., 1984).

`It was shown that among women who had opted for home confinement significantly fewer complications occurred during pregnancy, delivery and puerperium than among those who had their babies in hospital followed by a 24-hour stay there or followed by a seven-day stay in a maternity ward. Morbidity was also lower among the babies born at home than among those born in hospital.' (Damstra-Wijmenga,1984).

There is no evidence to support the claim that the safest policy is for all women to give birth in hospital. There is some evidence, although not conclusive, that morbidity is higher among mothers and babies cared in for in institutional setting. For some women, the iatrogenic risk associated with institutional delivery may be greater than any benefit conferred, but this has yet to be proven. (Campbell and Macfarlane, 1987).

Only midwives know about birth at home, only midwives (except for a tiny number of general practitioners) deliver babies at home, it is up to us to inform women of their right to have a baby at home - our name means `with woman', it is time we let women know that undoubtedly there are risks in childbirth, but that the risks of a home birth are no greater than a hospital birth and for some women they are indeed less.

References

Bottomley, V. (1990). Minister of Health opening the Royal College of Midwives Annual Conference, July 1990. Midwife, Health Visitor and Community Nurse, November.

Campbell, R., Davies, J.M., MacFarlene, A., Beral, V. (1984) 'Home births in England and Wales, 1979: perinatal mortality according to intended place of delivery.' British Medical Journal, 289, pp. 721-724. Campbell, R., MacFarlene, A. (1987). Where to be born, The Debate and the Evidence. Oxford, National Perinatal Epidemiology Unit.

Clarke, K., Secretary of State for Health. (1989). The Guardian, 21 st September.

Damstra-Wijenga, S.M.I. (1984). `Home confinement: the positive results in Holland.' Journal of the Royal College of General Practitioners. 34, pp.425-430.

Dunn, P.M (1976). 'Obstetric delivery today. For better or worse?' Lancet i pp.790-793. Enkin, M., Keirse, M., Chalmers,1. (1989). A Guide to Effective Care in Pregnancy and Childbirth. Oxford: Oxford University Press. Royal College of Midwives (1987). Towards a Healthy Nation. A Policy for Maternity Services. London.

Russell, J.G.B. (1982). `The rationale of primitive delivery positions.' British Journal of Obstetrics and Gynaecology, 89, pp.712715.

Tew, M. (1990). Safer Childbirth? London: Chapman and Hall.

United Kingdom Central Council for Nursing, Midwifery and Health Visiting, (1986). A Midwife's Code of Practice. London: UKCC.

World Health Organization (1985). Having a Baby in Europe. Geneva:WHO.

March 1991