Turbulente tijden in de geboortezorg; waar liggen de kansen?

                                     ‘Oude wijn in nieuwe zakken’ 
 

De KNOV, de beroepsorganisatie van verloskundigen, signaleert op landelijk niveau meerdere ontwikkelingen die zorgen baren. In de eerste lijn staat de zelfstandige en autonome positie van de verloskundige ter discussie. De verwijzingen vanuit de 1ste lijnsverloskundige praktijken naar specialisten stijgen door; zichtbaar zijn grote regionale en praktijk verschillen (tussen 30 en 70%). Kleine praktijken met maximaal twee verloskundigen doen het beter (Fontein, 2008). Caseload praktijken doen het nog beter, onderzoek ontbreekt nog. Verder zakt het aantal thuisbevallingen gemiddeld onder de 20%. Ook op dat punt doen kleine - en caseload praktijken het veel beter.

In de kliniek signaleert de KNOV een verdergaande medicalisering en protocollering van de geboortezorg (KNOV, 2014). Enorme verschillen, weinig consistentie (LVR 2) in aantallen ingrepen (Neef, Franx & Wouters, 2011). Dat terwijl rond de 60% van de klinische bevallingen begeleid worden door klinisch werkende verloskundigen (McNabb & Oudshoorn, 2011). Voor klinisch werkende verloskundigen is positionering en erkenning van hun toegevoegde waarde van cruciaal belang. De recente uitkomsten wijzen uit dat klinisch werkende verloskundigen weinig toegevoegde waarde leveren in ons land. Een onthutsend resultaat, dat door een aantal wijzen vrouwen uit de beroepsgroep tien tot 15 jaar geleden werd voorspeld als niet extra aandacht aan hun positie en aan verdieping van de kennis van ‘het normale’ werd besteed. Verder merkt de KNOV, die deregulering stimuleerde, dat in de regio’s inhoudelijk afspraken gemaakt worden waarbij verloskundigen niet altijd goed betrokken zijn bij de besluitvorming en er dus afspraken uitkomen die niet bij de beroepsgroep passen. Hieruit blijkt dat visie en regie ontbrak. Veel VSV’s worden gedomineerd door specialisten en dit werd versterkt door de keuze voor integrale verloskundige zorg. Ereleden van de KNOV hebben hier meermalen voor gewaarschuwd. Verder constateert de KNOV toenemende externe druk van verzekeraars en vrouwen, om de geboortezorg anders vorm te gaan geven.

 Kansen 

Het Nederlandse vakgebied verloskunde worstelt al ruim 20 jaar met de vraag waar het accenten moet leggen; bij 'plaats van bevalling' of 'bevorderen en beschermen van de natuurlijke bevalling'. Ik zie dat vooral de KNOV weinig expliciete doelen geformuleerd heeft over de jaren en er daardoor nauwelijks expliciete keuzes gemaakt zijn. Zoals bij de Maggi reclame, ‘een beetje van de Specialisten (NVOG, 2011) visie met 'een beetje van een beetje van onszelf' (KNOV, 2011)'. Verloskunde is ‘geen dagelijkse kost’ lieve lezer. Verloskunde door verloskundigen richt zich primair op behoud, verbetering en/of herstel van gezondheid van vrouwen en hun families op de korte en lange termijn. Een hoog en gewichtig doel dat beoogd dat vrouwen en hun families gezond leven en vrouwen zich in welbevinden voortplanten. Dat is het eeuwenoude doel en daartoe zijn vroedvrouwen aanwezig in de gemeenschappen sinds de vroegste tijd. Nederland met haar al ruim vóór het jaar 1500 geschoolde vroedvrouwen en vroedvrouwen structuur van zorg, diende lang als ‘best practice’. De visie erachter is ondubbelzinnig verwoord door WHO en ICM en wordt de ‘vroedvrouwenvisie’ genoemd (ICM, 2014; WHO, 1996). 

 

           Goed is ons van tijd tot tijd af te vragen waar het om gaat in de verloskunde van zowel verloskundigen, huisartsen en specialisten in ons land. Zien we nog sporen van de vroedvrouwenvisie en vroedvrouwen structuur van zorg in ons land? We gaan er van uit dat 90% of meer van de vrouwen spontaan kan bevallen. Wij stellen dat bevallen geen ziekte is en vrouwen gezond en in vertrouwen de zwangerschap moeten kunnen doorkomen en thuis kunnen baren (CVZ, 2003). We hebben 10 praktische ‘TOP tips voor normaal bevallen’ (Keijzer & Oudshoorn, 2009). De bevalling moet spontaan en 'op' tijd start starten en we vertrouwen erop dat vrouwen spontaan, zonder interventies en ‘op eigen kracht baren’ en daarna in vertrouwen gaan moederen. Verloskundigen faciliteren dit met preventie, primair en secondair en de specialisten staan vrouwen curatief bij, door geconstateerde problemen adequaat op te lossen, door zorgvuldig gebruik van technische middelen, ingrepen of anderszins om zo min mogelijk iatrogene schade te veroorzaken (Downe, 2004, WHO, 1996). Theorie en praktijk staan hier tegenover elkaar in ons land. Meer ingrepen dan nodig wordt geconstateerd, teveel verwijzingen. Internationaal zijn de WHO, ICM (verloskundigen) en FIGO (specialisten) het er unaniem over eens; niet onnodig medicaliseren, minder techniek gebruiken, continuïteit van zorg (één op één zorg en relatieopbouw) en evidence based werken. Samenwerking van specialisten met verloskundigen is nodig en aangewezen, geen twijfel daarover. Maar de verloskundige zal altijd primair autonoom en in een doorlopende relatie en in samenspraak met vrouwen de processen individueel moeten kunnen faciliteren als standaardzorg. Daar zit de kracht. De vrouw centraal, haar belangen en behoeften volgend en niet de behoeften van een instelling of zorgsysteem, zoals in het medische model van zorg.

De dagelijkse realiteit in ons land is, dat de 'plaats van bevalling' sterk aan het verschuiven is. Ik denk dat de recentste push het promoten via een nieuw protocol van ruggenprikken was. Hierbij is ingespeeld op gemak en ongedefinieerde angst van vrouwen en hun partners voor het baringsproces. Er is verder toenemende behoefte aan controle over de thuisbevallingen, het werkgebied en de verantwoordelijkheid van verloskundigen sinds eeuwen, bij specialisten, die vaak geen thuisbevalling zelfstandig begeleid hebben in hun opleiding. De NVOG pleit voor veiligheid boven vrije keuze (autonomie) van vrouwen en spreekt zich in haar notities uit tegen thuis bevallen (NVOG, 2011). Dit ten spijt van onderzoeken die ondubbelzinnig bewijzen dat thuisbevallen veilig en gezonder is en medicalisering tegengaat. De boodschap van de specialisten echoot beter door naar het publiek dan de boodschap van de verloskundigen. Al in de 60ger jaren, wilde artsen en beleidsmakers de verloskundigen naar de ziekenhuizen trekken om dezelfde reden. De poliklinische bevalling kwam in de mode om die reden, maar zorgde wel voor opvallend veel meer medicalisering van de spontane eerste bevallingen van puur gezonde vrouwen. Meer ziekenhuis bevallingen betekent meer interventies, weten we nu na veel nationaal en internationaal onderzoek. Ja, ook ik ging vrolijk mee met de mode en begeleidde veel poliklinische bevallingen van eerst barenden. Nu weet ik mede door ‘bergen’ evidence, meer inzicht in de fysiologie en andere ervaringen beter.

Wat in die tijd en ook nu nog altijd bij vrouwen speelt is de onbekendheid met bevallen, angst voor bevalpijn en gebrek aan vertrouwen het zelf te kunnen. Praten daarover in een vertrouwde relatie is ‘het’ recept. Bij artsen en verloskundigen is daar weinig oog voor door tekort aan vaardigheden; er is gebrek aan inzicht in fysiologisch verloop, weinig behoefte en schrijnend gebrek aan tijd voor de sociale interactie tussen vrouw en professional om soms triviaal lijkende problemen bespreekbaar te maken. Praten over ‘ditjes en datjes’ heeft zijn functie …..

Tijd besteden aan de opbouw en het onderhoud van een persoonlijke relatie blijkt het instrument te zijn voor meer spontane bevallingen, minder interventies en betere ervaringen van vrouwen. In het huidige tijdsvak is er echt veel meer behoefte aan individuele relaties van vrouwen met professionals dan voorheen, mede omdat het netwerk van de vrouwen veel minder ervaringsdeskundigen bevat, dan vroeger. Verder zijn er nogal wat vrouwen tegenwoordig hoog opgeleid en/of rationeel ingesteld. Gedurende de zwangerschap wordt onder de invloed van neuro-hormonale processen die rationaliteit minder en support van iemand die dat onderkend en benoemd is een reuze hulp. Meegaan met de neuro-hormonale veranderingen en er beter op inspelen helpt vrouwen om goed door de zwangerschap te komen en op tijd en spontaan te bevallen (McNabb, 2010).

                     Opvallend is de schaarse kennis over neuro-hormonale processen in ons land bij verloskundigen en artsen. De KNOV noch de NOVOG bieden scholing op dit punt. De focus in het Vademecum is medisch technisch, de sociaal psychologische zorg is samengevat in één alinea in het Vademecum, over neuro-hormonale processen staat geen woord. Niet zo gek dus dat geboortehuizen, die als paddenstoelen uit de grond rijzen, weinig gebruik maken van de methoden die fysiologisch verloop bevorderen en bevallen in bed daar nog de gewoonste zaak van de wereld is.

Recent wordt centuring pregnancy (groepsbijeenkomsten om vertrouwen van vrouwen te verhogen) omarmt door veel praktijken en gezien als een geëigende oplossing voor betere uitkomsten. Die methode compenseert het gebrek aan relatieopbouw onvoldoende en vult het tekort aan kennis over fysiologisch verloop niet aan.

In Hong Kong zag ik vorig jaar hoe het anders kan. Het door verloskundigen gerunde geboortecentrum in het Universitaire Kwong Wah ziekenhuis heeft jaarlijks 94% spontane bevallingen, waarvan er veel vertikaal plaatsvinden, omdat de verloskundigen zich daar extra bekwaamd hebben in de theorie van het fysiologische verloop van zwangerschap, bevalling en kraambed en methoden gebruiken om het gehele proces beter faciliteren (McNabb, 2010). Standaard wordt persoonlijke één op één zorg vanaf vroeg in de zwangerschap, de z.g. caseload verloskunde geboden. Dat is daar de basisvorm voor alle zorg door verloskundigen. Overigens kan centuring pregnancy daarbij wel een positieve rol spelen.

Wat is er op tegen als iedere vrouw in ieder echelon in ons land standaard haar eigen verloskundige treft tijdens de zwangerschap en daar een relatie mee opbouwt? Kost wat extra planning en tijd, omdat bij relatieopbouw en onderhoud gesprekken langer gaan duren. Ook part-time werkende verloskundigen kunnen zo relaties met vrouwen opbouwen door creatieve planning. De investeringen in planning en tijd betalen zich terug in meer spontane bevallingen en meer tevreden vrouwen. Voor een wat lagere caseload is het ‘zo ie zo’ tijd. Een goed begin van oude wijn in nieuwe zakken …..

Goed collega, dit is maar een los voorstelletje. Om tot echt betere vormen van begeleiding van zwangere en barende vrouwen te komen is eerst het weloverwogen beantwoorden van kernvragen nodig; ‘Wat en wie ben ik als verloskundige en wat voor model past bij mij en mijn vak?’; ‘Wat versta ik onder een fysiologische zwangerschap, bevalling en kraambed?’; ‘Wat is medicalisering in mijn perspectief en hoeveel medicalisering sta ik mijzelf en de groep waarin ik werk toe, in relatie met de WHO aanbevelingen?’; ‘Hoe pakken ik en mijn team/praktijk medicalisering praktisch aan?’; ‘In welke mate praten vrouwen mee in mijn team/praktijk en heeft de mening van vrouwen invloed op mijn aanpak en beleid?’; ‘Wat zijn mijn streefcijfers en wat zijn mijn uitkomsten? Aantallen spontane bevallingen, epi’s en andere interventies, verwijzingen enz.’; en ‘Hoe groot is het welbevinden van moeder en kind objectief gemeten vanuit het perspectief van de vrouw zelf in mijn zorggroep/team of praktijk?’

Terug naar af en opnieuw beginnen met de beproefde eeuwenoude methode van vroedvrouwen in een nieuw jasje. Nu de KNOV signaleert dat de keuze voor integrale zorg niet juist was, kan een U turn gemaakt worden. Niemand zal het de KNOV kwalijk nemen dat ze een fout maakten, immers wij allen maken fouten en nemen net zo vaak als zij opportunistische besluiten. Beter ten halve gekeerd, dan ten hele gedwaald!

Oude wijn in nieuwe zakken is het langzaam evidence based invoeren van het vroedvrouwen model van zorg in ons land dat zich voegt naast de medische zorg van specialisten en in de kliniek complementair zal werken. In de kliniek kan de continuïteit van zorg uit het model, ‘iedere vrouw haar eigen verloskundige’ die verbetering teweeg brengen die we theoretisch zouden mogen verwachten van klinisch werkende verloskundigen welke normaal baren nastreven. In de huispraktijk zullen de aantallen verwijzingen drastisch gaan dalen.

Dus waar liggen de kansen en hoe kan de KNOV u ondersteunen? De KNOV heeft ondanks alles nu een geweldige kans. Ze kan verloskundigen en vrouwen tegemoet komen door het vroedvrouwen model van zorg te promoten en het model behoedzaam (evidence based) en in samenspraak met vrouwen in te voeren. Inderdaad een lagere caseload hoort daarbij. Deze positieve uitdaging zal inspanning vragen, maar plezier en welzijn opleveren voor professionals en vrouwen op de korte termijn en in de verre toekomst.

 

Literatuur

Downe, S. (Redactie). (2008). Normal childbirth: evidence and debate. Oxford: Churchill Livingstone.

Fontein, Y. (2008). Minder is meer. De kracht van solo- en duopraktijken in Nederland. Tijdschrift voor verloskundigen. Vol.12:23-29.
ICM. (2014). The Philosofy and Model of Midwifery Care. Core document. http://www.internationalmidwives.org/Documentation/Coredocuments/tabid/322/Default.aspx.
KNOV. (2011). Missie en visie. http://www.knov.nl/knov/waar-staan-wij-voor/missie-en-visie/.
KNOV. (2014). Nieuwsbrief 16 januari 2014. ‘Turbulente tijden in de geboortezorg’.
Keijzer, Gré., Oudshoorn, Tine. (2009). Tien Top Tips voor normaal bevallen. Tijdschrift voor verloskundigen. Vol.34:(1):142-3. http://vvah.artsennet.nl/Nieuws/Artikel/Tien-TOP-Tips-NORMAAL-BEVALLEN-HAPPY-BIRTH.htm
NVOG. (2011). Integrale verloskundige zorg in Nederland. Een stap verder.
McNabb, M. (2010). An educational, research module for experienced midwives to utilise recent neuro-bio-social research findings on maternal-fetal, neonatal and paternal adaptations to the fertile cycle, with the aim of reducing perinatal mortality and morbidity in term infants ( module is in use in Hong Kong and the UK).  
McNabb, M., Oudshoorn, C. (2011). Moves to transform midwifery. AIMS Journal. Vol:23:(3):19-21.
Neef de, T., Franx,  A ., Wouters, M.G.A.J. (2011). Wat ons opviel in de LVR2. Vrijheid van handelen. Nederlands Tijdschrift voor Obstetrie & Gynaecologie. Vol.124:474–76.
CVZ. (2003). Verloskundig Vademecum 2003.  Amstelveen: College voor zorgverzekeringen.
WHO, World Health Organization. (1996). Care in normal Birth: a practical guide. Maternal and newborn health/safe motherhood unit, family and reproductive health. WHO1211.WHO: Geneve.

 

 

VISIE

    
 
  You are assisting at someone else’s birth
  Do good without show or fuss
  Facilitate what is happening rather than
  what you think ought to be happening
  When the baby is born, the mother will
  rightly say: ‘WE DID IT BY OURSELVES’


Lao Tzu, the Tao of leadership (5th century BC)

WAKE UP

WAKE UP Call....... Ina May Gaskin 

 

         We must wake up to the fact that it is easy to scare women about their bodies, especially in countries in which midwives have little or no power in policy-making, relative to physicians and the influence of large corporate entities. This takes no real talent. Given such imbalance, fear ignorance, and greed begin to reinforce each other, and rates of unnecessary intervention soar, with women and the babies suffering the consequences. Birth care must not be profit-driven.

        This makes incentives to cause problems, not prevent them. For this reason, there should be no more fee-for-service payment – for instance, financial reward for the unnecessary use of a vacuum extractor.

        If all countries put the welfare of mothers and babies at the centre of maternity care policy, midwifery would have to grow strong again. In some countries, such as my own (USA), it will be necessary to greatly increase the number of midwives as just one of the ways to prevent complications and to reduce rates of medical intervention in birth. We’ll need lots of doulas as we make this transition. Midwives need to have a say in the major issues surrounding birth.

 

        In countries where they currently work under the intense domination of obstetricians, the work will be to bring the relationship back to one of balance. Midwives cannot allow obstetricians to bully them, because doing so is almost certain to mean that labouring women will be the next ones to be bullied.

        Attempts to make home birth illegal in any country (happens in many European countries) will only distract from the real problems and exacerbate them, since planned home birth for healthy women provides a necessary safety valve for women who want a wider range of choice than their hospital might offer and a learning opportunity for midwives to learn about women in their natural state. Home birth midwives must be able to make a living from their work, and insurance companies should not be permitted to keep home birth midwives from being compensated for their work. Home birth midwives are being persecuted in almost every country, even in The Netherlands (see the results of Tuchtzaak Midwives, July 16 2013), where home birth services have a long and honourable tradition. I believe the development of a country can be measured by the degree to which it respects the right of a birthing mother to receive a woman centred birthing experience, whether the birth occurs in a home or hospital setting.

 

        In this regard the current situation in Hungary greatly disturbs me. There, the failure to fully provide and protect this important right is highlighted by the prolonged discrimination and mistreatment of the independent midwife Dr. Agnes Gereb. Agnes has spent more than 20 years trying to defend the fundamental rights of mother and child and in doing this she has been imprisoned, recently received a further 2-year prison sentence and has been held under house arrest for the past year.

        Birth shouldn’t be thought of as money-making commodity or condition in which large institutions or governments control and dictate how women will give birth, ignoring individual mother’s wishes and needs. Inevitably, this too often puts bullies in charge of women’s bodies, something no other mammalian species allows. Some countries have midwives who are totally subordinate to physicians. In these countries, it’s typical for very harsh methods of birth care to be applied, and outcomes show this. It’s time to stop this sort of behaviour.

 

       Traditional people, indigenous people don’t permit such behaviour. We need to learn from them.

Ina May Gaskin, part of the speech by receiving the Right Livelihood Award 2011

http://rightlivelihood.org/press_room.html

 

Posttraumatische stress-stoornis (PTSS) en verloskundig geweld

PTSD and Obstetric Violence

Dr. Ibone Olza Fernández, perinatal psychiatrist and associate professor of medicine at Autonomous University of Madrid, Spain.

Childbirth can be a traumatic event for many women. Different studies have found a high prevalence of trauma symptoms following childbirth. In a British study, up to a third of all women reported that labour was traumatic and that they feared they or their babies would die or be seriously injured (Soet, Brack and DiIorio 2003). Population-based studies from Australia and the UK indicate that between 1% and 6% of women will develop complete post-traumatic stress disorder (PTSD) following childbirth (Creedy, Shochet and Horsfall 2000; Ayers and Pickering 2001). In the US, a national survey found 18% of women were experiencing elevated levels of PTSD symptoms (Beck et al. 2011). Approximately 35% of women present some degree of PTSD symptoms postpartum (Soet, Brack and DiIorio 2003; Creedy and Shochet 2000; Allen 1998) .

Birth trauma has been defined as “Actual or threatened injury or death to the mother or her baby” (Beck 2008). Many healthcare professionals ignore or do not recognize the signs of psychological and emotional trauma (Beck 2004). As Beck states, “Birth trauma lies in the eye of the beholder,” implying that birth trauma is what women view to be traumatic during their childbirth experience (Beck 2004). A traumatic birthing experience is often accompanied by fear, helplessness and terror, and is subsequently associated with a range of thoughts including vivid memories of the event, flashbacks, nightmares and irritability (Ayers 2004; Olde et al. 2006). It can have a severe impact on women and their families.

Qualitative studies have shown that a main issue for these traumatized women was the inadequate quality of care (Allen 1998). A meta-ethnographic analysis of studies about women’s perceptions and experiences of a traumatic birth reported that women are often traumatized as a result of the actions or inactions of midwives, nurses and doctors (Elmir et al. 2010). In that review, women described having no control over their birthing experience. Their opinions were ignored and they were subjected to authoritarian decision-making. Women also felt healthcare professionals failed to consider them as individuals with a right to make informed decisions (Thomson and Downe 2008). They felt betrayed, and some indicated that they agreed to procedures such as epidural analgesia and vacuum extractions in an attempt to end the trauma they were experiencing (Goldbort 2009). The care received was sometimes experienced as dehumanizing, disrespectful and uncaring. Words such as barbaric, intrusive, horrific and degrading were used by the women to describe the mistreatment they received from healthcare professionals (Thomson and Downe 2008). Other participants talked of feeling like a “lump of meat” or a “slab on a table” when describing the dehumanizing way in which they were treated during birth and described a total lack of acknowledgement of them as humans (Beck 2004; Thomson and Downe 2008). They wanted the ordeal of birth to end, with thoughts of death as a way to escape from the intense pain and trauma (Thomson and Downe 2008). Many held vivid memories of the experience of a traumatic birth for many years. It is possible that abusive care can have a bigger impact when it happens during childbirth, a time when the maternal brain is imprinted with specific neurohormones that make it ready for initiating attachment.

In sum, the findings of the studies indicate that women are often traumatized as a result of the actions or inactions of midwives, nurses and doctors (Elmir et al. 2010).

Childbirth activists have given a different perspective to define this mistreatment of laboring women by health providers and to make visible the emotional sequel of such care. Interestingly, abuse has been named almost solely by people who define themselves as childbirth activists, such as Susan Hodges (President of Citizens for Midwifery) or midwife and homebirth advocate Shelia Kitzinger. It is worth mentioning that childbirth activism is frequently a sequel of traumatic childbirth (Sawyer and Ayers 2009). According to Hodges, naming the abuse that many women experience in labor is the first step to stopping the problem. For Hodges, drugging or cutting a pregnant woman with no medical indication is an act of violence, even when performed by a medical professional in a hospital. Inappropriate medical treatment, such as the practice of administering Pitocin until the baby goes into distress (and cesarean surgery is called for), is also clearly abusive, although few women are aware that this is deliberate mistreatment (Hodges 2009). Kitzinger highlighted that for some women, birth is experienced as rape and that many women suffering from traumatic birth display similar symptoms to rape survivors (Kitzinger 2006). The term birth rape has been used by women who feel that their bodies have been violated and that they have been coerced into consenting to procedures without being informed of the details and accompanying risks.

It is difficult for healthcare professionals to accept the term rape when talking about childbirth in a medical setting. However, birth attendants are often also traumatized by this very insensitive care. Nurses may feel powerless to intervene. In a recent study by Beck, 26% of obstetric nurses met all the diagnostic criteria for screening positive for PTSD due to exposure to their patients who were traumatized (Beck and Gable 2012). Being present at what L&D nurses termed abusive deliveries magnified their exposure to birth trauma. In that qualitative study, nurses frequently used phrases such as “the physician violated her,” “a perfect delivery turned violent,” “unnecessary roughness with her perineum,” “felt like an accomplice to a crime” or even “I felt like I was watching a rape.” The guilt that ensued when nurses felt like they had failed their patients when they did not speak up and challenge/question the obstetricians’ practices was very distressing (Ibid).

Venezuela was the first country to recognize obstetric violence as a legal term. The “Organic Law on the Right of Women to a Life Free of Violence” was published in Venezuela's Gaceta Oficial (Official Gazette) in March 2007 (D’Gregorio 2010). In Article 15:19, obstetric violence is defined as “…the appropriation of the body and reproductive processes of women by health personnel, which is expressed as dehumanized treatment, an abuse of medication, and to convert the natural processes into pathological ones, bringing with it loss of autonomy and the ability to decide freely about their bodies and sexuality, negatively impacting the quality of life of women.” Article 51 establishes that:

The following acts implemented by health personnel are considered obstetric violence:

1.       Untimely and ineffective attention of obstetric emergencies;

2.       Forcing the woman to give birth in a supine position, with legs raised, when the necessary means to perform a vertical delivery are available;

3.       Impeding the early attachment of the child with his/her mother without a medical cause thus preventing the early attachment and blocking the possibility of holding, nursing or breastfeeding immediately after birth;

4.       Altering the natural process of low-risk delivery by using acceleration techniques, without obtaining voluntary, expressed and informed consent of the woman;
5.    Performing delivery via cesarean section, when natural childbirth is possible, without obtaining voluntary, expressed, and informed consent from the woman.(D’Gregorio 2010).

From the consumer’s point of view, the term obstetric violence is very easy to understand, and it may help many women disclose their traumatic births as a first step towards emotional recovery. But from the professionals’ perspective, a deepening of the understanding of obstetric violence may be crucial. Obstetric violence may be the consequence of extreme medicalization of childbirth (which also includes the denial of its spiritual dimension) (Callister 2004).

                Professionals may exert obstetric violence because of different reasons:

1.       Lack of technical skills to deal with emotional and sexual aspects of childbirth.

2.       Unsolved trauma. The medicalization of childbirth produces more severe iatrogenic complications (Johanson, Newburn and Macfarlane 2002; Belghiti et al. 2011).
If the professionals do not have a supportive space to reflect or to deal with this aspect of iatrogenic care, they may fall into a spiral of continuously increased medicalization as a defensive strategy. Childbirth is then perceived as a very dangerous event, “a bomb ready to explode,” without realizing that interventions cause more unnecessary interventions and pain.

3.       Professional burnout. By birth attendants this lead to increased dehumanized care and therefore never-ending figures of women experiencing childbirth as very traumatic.

Starting the dialogue around obstetric violence can help close the circle and end the violence by understanding the close link between PTSD and traumatic symptoms following childbirth, the abusive care received and the causes that produce that type of care, as well as the hidden emotional pain many birth attendants carry within their souls. Models of midwifery-led care can increase the continuity of care and facilitate women’s active participation in their birth experiences. Ongoing dialogue between consumer groups and health care professionals is a necessary task in ending obstetric violence.

Reference

(1) Soet JE, Brack GA, DiIorio C. Prevalence and predictors of women's experience of psychological trauma during childbirth. Birth 2003 Mar;30(1):36-46.

(2) Creedy DK, Shochet IM, Horsfall J. Childbirth and the development of acute trauma symptoms: incidence and contributing factors. Birth 2000 Jun;27(2):104-111.

(3) Ayers S, Pickering AD. Do women get posttraumatic stress disorder as a result of childbirth? A prospective study of incidence. Birth 2001 Jun;28(2):111-118.

(4) Beck CT, Gable RK, Sakala C, Declercq ER. Posttraumatic stress disorder in new mothers: results from a two-stage U.S. national survey. Birth 2011 Sep;38(3):216-227.

(5) Allen S. A qualitative analysis of the process, mediating variables and impact of traumatic childbirth . Journal of Reproductive and Infant Psychology 1998;16(2-3):107-131.

(6) Beck CT, Watson S. Impact of birth trauma on breast-feeding: a tale of two pathways. Nurs Res 2008 Jul-Aug;57(4):228-236.

(7) Beck CT. Post-traumatic stress disorder due to childbirth: the aftermath. Nurs Res 2004 Jul-Aug;53(4):216-224.

(8) Beck CT. Birth trauma: in the eye of the beholder. Nurs Res 2004 Jan-Feb;53(1):28-35.

(9) Ayers S. Delivery as a traumatic event: prevalence, risk factors, and treatment for postnatal posttraumatic stress disorder. Clin Obstet Gynecol 2004 Sep;47(3):552-567.

(10) Olde E, van der Hart O, Kleber R, van Son M. Posttraumatic stress following childbirth: a review. Clin Psychol Rev 2006 Jan;26(1):1-16.

(11) Elmir R, Schmied V, Wilkes L, Jackson D. Women's perceptions and experiences of a traumatic birth: a meta-ethnography. J Adv Nurs 2010 Oct;66(10):2142-2153.

(12) Nicholls K, Ayers S. Childbirth-related post-traumatic stress disorder in couples: a qualitative study. Br J Health Psychol 2007 Nov;12(Pt 4):491-509.

(13) Ayers S. Thoughts and emotions during traumatic birth: a qualitative study. Birth 2007 Sep;34(3):253-263.

(14) Thomson G, Downe S. Widening the trauma discourse: the link between childbirth and experiences of abuse. J Psychosom Obstet Gynaecol 2008 Dec;29(4):268-273.

(15) Goldbort JG. Women's lived experience of their unexpected birthing process. MCN Am J Matern Child Nurs 2009 Jan-Feb;34(1):57-62.

(16) Sawyer A, Ayers S. Post-traumatic growth in women after childbirth. Psychol Health 2009 Apr;24(4):457-471.

(17) Hodges S. Abuse in hospital-based birth settings? J Perinat Educ 2009 Fall;18(4):8-11.

(18) Kitzinger S. Birth as rape: There must be an end to ‘just in case’ obstetrics. British Journal of Midwifery 2006;14(9):544-545.

(19) Beck CT. The anniversary of birth trauma: failure to rescue. Nurs Res 2006 Nov-Dec;55(6):381-390.

(20) Beck CT, Gable RK. A Mixed Methods Study of Secondary Traumatic Stress in Labor and Delivery Nurses. J Obstet Gynecol Neonatal Nurs 2012 Jul 12.

(21) Perez D'Gregorio R. Obstetric violence: a new legal term introduced in Venezuela. Int J Gynaecol Obstet 2010 Dec;111(3):201-202.

(22) Callister LC. Making meaning: women's birth narratives. J Obstet Gynecol Neonatal Nurs 2004 Jul-Aug;33(4):508-518.

(23) Johanson R, Newburn M, Macfarlane A. Has the medicalisation of childbirth gone too far? BMJ 2002 Apr 13;324(7342):892-895.

(24) Belghiti J, Kayem G, Dupont C, Rudigoz RC, Bouvier-Colle MH, Deneux-Tharaux C. Oxytocin during labour and risk of severe postpartum haemorrhage: a population-based, cohort-nested case-control study. BMJ Open 2011 Dec 21;1(2):e000514.

Dr. Ibone Olza Fernández is the co-founder of the Spanish consumer group El Parto Es Nuestro (Childbirth Is Ours) and of the cesarean support email list Apoyocesareas.

Wat is er aan de hand met de verloskundigen?

Sheila Kitzinger’s Letter from Europe:

What’s Happening to Midwives in Europe?

Published  March 2004. BIRTH, 31:1:68-70.

The whole system of maternity care in Britain is based on midwifery. Because obstetricians are specialists in pathology, without midwives care in childbirth would collapse, and most women have to give birth attended only by family and friends.

Throughout Western European countries midwives are the main caregivers. What doctors learn about normal birth they acquire largely from midwives. On the whole, women don’t need obstetricians, but there is no question that they need midwives.

Wherever autonomous midwifery exists—in the Scandinavian countries, the Netherlands, where one third of births take place at home, and New Zealand—perinatal mortality rates are the lowest in the world.

Although midwives are qualified to provide total care in pregnancy, birth, and afterwards, they have had little influence on formulating public health policies, and institutions representing obstetricians speak with a louder and more authoritative voice.

In Germany and Italy, maternity clinics are similar to the United States model. When I observed births in hospitals in Northern Italy, for example, I witnessed women waiting to give birth until the obstetrician put in an appearance. They were ordered not to push, however much they wanted to. Midwives were not supposed to deliver, except in an emergency. The obstetrician enters, performs an episiotomy, and delivers, often employing fundal pressure and using a manoeuvre that entails sticking a finger in the woman’s anus and forcing the baby’s chin up over the perineum.

In Eastern Europe Communism introduced totalitarian and highly bureaucratic medical control of childbirth. It is still the norm. Zuzana Stromerova, of the Czech Association of Midwives, says: “ Under the Communist regime midwives were a small body of professionals who had little power and had to do as they were told” (1). There is no midwifery legislation or laws referring to midwifery in the Czech Republic. Midwives are not recognized legally as an autonomous profession…and are called “women’s nurses.” She went on to say that doctors “view a normal birth as a potential crisis, not a normal event in life, and it is doctors who are considered the experts.…Hospitals are not paid by health insurance companies unless there is a signature from the doctor on duty or chief doctor.” So an independent midwife, if it were possible for her to exist, would get paid nothing. Birth is the responsibility of obstetricians.

Out-of-hospital births are forbidden by law, and a midwife can be punished for helping a women

have a planned home birth, as can the mother.

World Health Organization (WHO) report (2) on midwifery in Central and Eastern European countries states “Doctors are the lead professionals in birth…Midwives hold the position of doctor’s assistant and are often not advocates of women. Home birth is neither attended by midwives nor supported.… Midwives provide care immediately following the birth but not in the postnatal period.… Midwifery practise is not based on the latest evidence and research… Legislation states that ‘Midwives work under the authority/direction of a doctor.’ There is no register for practising midwives…Midwives have little influence in the setting of national policies…No local structures exist which monitor standards of midwifery practice.” Commenting on midwifery education, the WHO report observed that up to 65 percent of time is spent on theory and never more than 40 percent on practice. “There are no midwifery training establishments. There are no nursing establishments affiliated with institutes of higher education” (2).

The situation is particularly bad in Hungary.

Maternal and child health nurses, not midwives, are the primary caregivers for pregnant women. Midwives work under the supervision of doctors and, according to WHO, although midwifery practice is claimed to be evidence-based, it “is dependent on the physician’s practice and philosophy of the institution” (3). Home births are banned. The Board of Obstetricians and Gynecologists has issued two statements about home birth (3):

·         First, “Pregnancy is a biological process that has several special patho-physiological features even in ‘normal’ cases. Pregnant women must not endanger the health or life of their fetuses/new-born babies by rejecting birth in a clinic/hospital.”

·         Second, “The restoration of home births would, even after significant investments, endanger the safety of child-births, and put the health and lives of mothers and new-born babies at risk.”  Section 17(2)a) of the Health Care Act proclaims that “pregnant women do not have the right to autonomously decide in this issue, and thus cannot reject maternity treatment in hospital.…The outstanding results of Hungary’s obstetrics in reducing perinatal mortality have always been accreditable to institutional births.… Women about to give birth need the constant availability of emergency service” (4). The Health Care Act rules, “a pregnant woman must not reject life-saving or life-maintaining intervention. Pregnancy is not among the exceptional situations when a patient is legally allowed to reject health-care provisions” (4). That includes delivery in hospital and compliance with any obstetric interventions that are considered necessary by the professionals in charge.

Ten new members are joining the European Community in 2004, including these Eastern European nations. They are required to change their maternity care systems to meet the European Community standard, and will have to give midwives professional and autonomous status, although they are allowed 2 years in which to make these adjustments. It will be a huge challenge.

Meanwhile a new restlessness is occurring among midwives in the United Kingdom, with lively debate about how to promote normal childbirth, really listen to women, and work with those who want to avoid obstetric interventions and high-tech management. Midwifery is also being examined in terms of the needs of a society in which deprivation starts, for many people, at birth.

This year the Government will publish a National Service Framework for children, young people, and the maternity services, and midwives are in the forefront of initiatives to identify how they can serve the most vulnerable in our society. Sure Start projects have begun to address drug and alcohol addiction in pregnancy, and the needs of teenage pregnant women, ethnic minority families, and travellers. More options for home birth are opening up, together with birthing units run by midwives.

Meryl Thomas, Vice President of the Royal College of Midwives, says: “There is evidence that women wish to have, and improved outcomes are more assured by, one-to-one care by a midwife for a woman throughout labour” (5,6). “There is also a significant number of women who would like to have a non-interventionist, normal childbirth experience and the option to give birth in a midwifery-led environment, or in a purpose designed birthing centre” (5,7). She stresses that midwifery is an autonomous profession, and that capitulation to the views of other professionals is not appropriate, whereas reasoned argument is.

On the other hand, midwives are leaving midwifery in droves. Of the 43,590 registered midwives, 32,190 are practicing (data for March 31, 2003) and 11,400 qualified midwives are not practicing. In statistics soon to be published, around 4,000 left in 2003. For some this is because they simply wanted a midwifery qualification in order to get a senior post as a health care professional. Policy makers often discuss the midwife shortage as if it were solely a matter of low pay and working conditions that are incompatible with family life. Both of these may be true, but there is more to it. Many are dissatisfied because they did not go into midwifery to spend their time filling in forms, manipulating machinery, and having to switch their attention between 3 or 4 women in labor at the same time, leaving them supervised only by continuous electronic fetal monitors and rendered compliant with epidurals. They entered midwifery to give woman-to-woman care.

Not only do mothers often not receive this quality of care, but midwives are denied the opportunity to give it. National statistics prepared by the United Kingdom Government Statistical Service reveal that the proportion of births conducted by midwives in the year 2001/2002 fell to 65 percent from 1989/1990, when it was 76 percent. Only 45 percent of women gave birth “without intervention” (i.e., no induction, spinal, epidural, or general anesthesia, and no instrumental delivery or cesarean section) compared with 56 percent in 1991/1992; 21 percent of labors were induced, and the cesarean rate increased from 21.5 percent to 22.3 percent. The proportion of hospital deliveries that occurred spontaneously is approximately 67 percent, having fallen steadily from 78 percent in 1989 (8).

With increasing dependence on technology and more obstetric intervention, midwifery skills are eroded. At the same time, midwifery education has improved. Although more and more graduate midwives are entering the profession, many find that they are unable to have some control over their work, use their skills, and make decisions. They encounter a working environment that is hostile and blame seeking. Midwives are set against midwives, and intimidation and “horizontal violence”  is prevalent (2–11). It is very difficult for midwives to continue to give supportive care to women when they themselves feel unsupported.

               

But this is not all. Mavis Kirkham, Professor of Midwifery at Sheffield University, tells me: “The problem with midwifery is bureaucracy. Midwives get totally disillusioned and leave as practice gets rule-driven. We are all policing each other. It is not medical oppression. It is bureaucratic oppression. Midwives are supposed to be autonomous. But we are caught in a bureaucratic trap.”

The depressing conclusion may be drawn that, rather than Eastern European midwifery being transformed to the standard of midwifery accepted in Western European countries, in Britain midwifery is at risk of being degraded to conform with the totalitarian East European model.

References

1. Stromerova Z. Royal College of Midwives International Conference, Vienna, Oct, 2002.

2. World Health Organisation. Profiling Midwifery in Newly Independent States and Countries of Central and Eastern Europe. Geneva: Author, 2003.

3. PappZ, ed. Statement of the Board of Hungarian Obstetricians and Gynaecologists on Home Birth, Budapest, Hungary, Jan 18, 2002.

4. Statement of the Board of Hungarian Obstetricians and Gynaecologists on Home Birth, Budapest, Hungary, Feb 26, 1999.

5. Thomas M. The crest of the wave—will midwives ride it? MIDIRS Midwifery Digest 2003;13:3.

6. Page L, Beake S, Viaol A. Clinical outcomes of one-to-one midwifery practice. Br J Midwifery 2001;9:700–706.

7. Boulton M, Chapple J, Saunder D. Evaluating a new service: Clinical outcomes in women’s assessment of the Edgware

Birth Centre. In: Kirkham M, Ed. Birth Centres: A Social Model for Maternity Care. Oxford: Elsevier Science, 2003.

8. National Health Service. Maternity Statistics, England: 2001/2002. Bulletin 2003/09, 2003.

9. Fanon F. The Wretched of the Earth. New York: Grove Press, 1963.

10. Leap N. Making sense of “horizontal violence” in midwifery. Br J Midwifery 1997;5:689.

11. Ball L, Curtis P, Kirkham M. Why Do Midwives Leave? London: The Royal College of Midwives, April 2002.