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.
[pullquote align=”right” cite=”” link=”” color=”” class=”” size=””]The report uses the views of what midwives believe women want (unpublished, no less!) instead of the actual views of women.[/pullquote]
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.
