The Doula
Natalie Meddings is the author of How to Have a Baby and Why Home Birth Matters and runs the support site, www.tellmeagoodbirthstory.com, which matches pregnant women with women who have had positive experiences of birth. She trained with Janet Balaskas as an active birth teacher in 2003 and has been teaching her yoga class in SW London for almost ten years. She trained as a doula with Michel Odent and Liliana Lammers, and has been supporting women in labour for fifteen years. She has three children of her own, Constance, 16, Pearl, 14 and Walter 11.
Hi Natalie, thanks so much for talking to me. Who are you, and what do you do?
Hi, I’m Natalie, I’m a doula and active birth teacher, founder of Tell Me A Good Birth Story, and author of How to Have a Baby and Why Home Birth Matters.
As you know, many of the women in the Make Birth Better campaign talked about feeling that they went into birth very unprepared, not expecting birth to go the way it went. What do you wish mums and their partners knew before birth?
Only 25 % cent of women say they want to give birth on a medical ward. That means 75% of women want to give birth without medical interventions, either in a birth centre, midwife-led unit or at home. In reality, around 15% of women give birth in a stand-free or attached birth centre or at home, which means there will be a lot of women feeling disappointed and confused as to why they ended up in the situation they did.
Heartbreakingly, too many mothers end up blaming their bodies for things not going as they planned, but the things that contribute to birth being complicated are more complex than that. Many things can lead to medical interventions, genuine medical issues being one. But inadequate birth education, an absence of experienced, encouraging support, as well as an increasing number of births being induced are the cause of a whole lot more. Except women who are left disappointed or even traumatised by birth are rarely helped to see this. They blame their bodies. Or feel persuaded to bury their hurt and told all that matters is having a healthy baby.
One of the main reasons birth becomes complicated for so many is women underestimating what they were going to need in birth (as in physiologically need, e.g. quiet, privacy, darkness, loving care), and overestimating what standard maternity care in a routine setting will provide.
One thing that can help women to prepare practically for birth is to understand what is going to happen - to have a really clear idea of how labour is going to feel and pacing themselves around that. For example it it's important to know what active labour is, or that there's a difference between contractions (the ‘wheels on the car’ – the mode of propulsion) and labour itself (the body opening). Women have been told to count contractions, go by dilation scores… As a result, they expect to be told when they are in labour instead of to understand (and find out in advance) what it is all going to feel like.
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I think it would be useful if chats along these lines could happen in midwife appointments. I know there isn't much time in these, but it's kind of extraordinary that there's pretty much zero relayed in terms terms of practical, positive information on how labour is going to feel; or what a woman might consider and get in place in terms of knowledgable support or ways to manage. Some guidance at this point could really make a difference.
The idea that women are individually good or bad at birth – that some manage and some don’t – is nonsense. What the female body needs to give birth applies to all women and though choices around setting and support will vary person to person, birth biology – what helps a baby be born – is universal. But everyone talks about choice, or about 'how' they want to give birth rather than first getting in place what is necessary for all, regardless of personal circumstances. For example, even a mother having a planned caesarean can benefit from deep, slow breathing and knowing how to relax to order. And even if someone is planning to go to labour ward for an epidural, a substantial part of the labour is still going to be done at home, meaning resources - ways to get comfortable - need to be in place by default.
Many mums also talked about feeling particularly unprepared for emergency situations. Do you think women could be better prepared for this?
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Women need to know that if they are induced, there is a strong chance further interventions will be needed and that an artificially prompted labour very often leads to a caesarean or instrumental delivery. I think it's around the issue of induction that women are left most unprepared and that's because at maternity appointments, the whole picture is rarely given. Information is incomplete - about the pros and cons of each route, waiting or inducing or managing the situation with monitoring for example which is another pathway open to her. I have never in 15 years heard of a woman in this situation be given the outcome statistics for induction at a particular hospital - i.e. what is likely to happen following an induction Instead they get told things like there is no 'evidence' that induction increases the chance of caesarean. For induction alone, that's true, but an induction plus epidural anaesthesia - a situation where the mother could well be immobilised for many many hours, under those circumstances there is huge chance of the baby not delivering easily but this is rarely explained.
Additionally, information about the risk of going overdue is rarely set in context. For example the risk at 41 weeks needs to be set against the risk at 35, 37 and 39 weeks for example...as well as 40 and 41, otherwise how can she assess the curve accurately?
The risk increases from -.09% at 40 weeks for a woman under 40 to 0.16% at 42 weeks. Some women will consider that worrying and want to be induced, others won't and will feel happy to wait - but that is their decision to make not the Trust's. Further context could and should be given for example by also reminding women of the NICE guideline on the start of labour - i.e. that most women will go into spontaneous labour by 42 weeks. That simple fact is often forgotten. Certainly women are rarely reassured of it. And also that even if they were to wait until 43 weeks, that's still a 99% chance of a totally healthy outcome. Given the last weeks of pregnancy are a sensitive time, isn't it important that positives like this are stressed - the way it's presented it all to often frightening and bleak so is it any surprise that mothers then feel they're being irresponsible not being induced? But it's just not as simple as that. Both routes carry risk and women need to know that to make the decision that feels right for them.
The other aspect to women feeling unprepared is on the 'Failure to progress' issue.
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In very many cases, labour NOT working will not be failure of the mother's body to 'birth'. It will be thanks to the conditions in which she is EXPECTED to birth. In a hospital setting, labour is for the most part 'stress tested'. Failure to progress, the common summation written on notes, is in fact a very appropriate response of the body in such circumstances. Women very often labour smoothly at home but the artificial disjoint of wondering when to go in, going in, what they are met with (triage which is a very public, transactional experience) can easily slow labour, which in turn makes it less manageable. If labour slows, endorphins often dip - certainly a labour that stalls usually results in a woman becoming more aware of the pain. Obviously, routine labour ward conditions, including the way women are welcomed even to birth centres is entirely antagonistic to physiology - the wards look like any ward in hospital, where people are patients. Women, like all mammals, require certain conditions to labour productively, and yet the atmosphere in most maternity settings remains interruptive, brightly lit, discontinuous, sterile feeling etc...Even if you are heading for a birth centre, you will have to navigate a bit of an awareness-raising obstacle course to get there.
Last of all, most women are unaware of the effect of vaginal exams on the progress of labour - finding out a number, the whole laying back and having someone you've never met put their hands in you (this used to be done by a midwife you'd become familiar with and whom you trusted and is now by a total stranger you may never see again). Again, it's a matter of biological fact that if you stimulate the cortex of any mammal female while they are birthing, oxytocin (the hormone driving labour) will slow. What is an assessment - a number on how you are doing, a plotting of the labour on a graph - if it's not intellectual? The woman now self- evaluates and this impacts on so many things - her ability to cope, maintaining labour's flow, having the fullest chance possible listening to her body. Just this single, simple act can be enough to throw a woman's focus off.
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Many women spoke about feeling that they were not listened to, or that the language used was not respectful (or, sometimes, aggressive). Do you have any thoughts on this?
As a doula, I try to avoid all language that brings the woman into her ‘conscious’ self. Any mention of time frames, birth as linear journey, any sense of a destination. I also think maternity care underestimates the need for silence in birth. Total quiet helps a mother to immerse herself in what she's feeling, to listen and follow contractions, growing changes in her body etc and this in turn helps her to cope - to relax and trust what's happening. Labour demands a kind of deep physical concentration .When the mother has the chance to do that, the hormone oxytocin as well as powerful endorphins flows fully But language that engages the mother will disturb that flow and leave the mother underpowered. I think maternity care language can be objectifying - jargon like 'you are fully' or 'cracking on' or 'we're crowning' …certainly the way it is delivered anyway. As if you're body has just hit or not hit a particular prescribed milestone, rather than what it is doing, which is unfolding itself in its own time, on its own terms.
The language of birth these days is often underpinned by a framework - the way it's managed rather than what it feels like for the mother herself. Telling a woman she is a ‘primip’, or that she has ‘srommed’, or that there is ‘kaput’..these descriptions encrypt the birth process and serve to distance the woman from what she is feeling and her own control over it.
Many of the stories in the campaign also described birth stalling, which led to further (again, unexpected) interventions. When birth stalls, or a baby becomes stuck – why do you think this happens?
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Often, because women are lying on their back, or in semi supine positions which close the pelvis by 27 per cent, and don't enable rotation. Babies also get stuck when the woman is told she is fully dilated and 'needs to push’. This sudden last minute wake up of the neocortex (your ‘thinking’ brain) causes oxytocin to drop, and she becomes UNDERpowered. Those last expulsive contractions become less effective, so she needs help. This often gets blamed on a big baby or pelvis size, but in most cases it’s because she's been disturbed.
There are sometimes true obstetric emergencies. How do you manage these as a doula?
I meet with the mothers I support several times, and we prepare thoroughly. The preparation rests on them having a very clear and realistic set of expectations. If they are healthy, and their pregnancy uncomplicated, they have a massive 90% chance of an entirely straightforward birth. Though less likely, there is still that 10% chance of labour taking an unexpected turn. It's important to know that so that should it happen, the mother can accept it and any help she may need as necessary. It's not a failure, or even a disappointment. It's just biology and if things aren't unfolding simply, what can you do? Surely we just need to be glad and grateful that we live in the times that we do. I'm very clear on this - the mother is intentioned in advance of the birth but when labour begins, there is space - openness.
We go through all this, and get very clear that whatever happens, what is vital is to be at the centre of the experience. The fact that they have a doula means that loving support is on tap. I think when birth does get complicated and there is no extra pair of hands or someone familiar and knowledgable around, it can be hard on partners - both mother and partner can feel stressed and unsure and that's not easy. This is where doulas can come in very handy! Explaining what's happening, keeping a perspective, going through the options and make sure the mother is being listened to. Sudden emergencies are extremely extremely rare. I've seen two in 15 years. Which means in most situations where the plan has changed, there is almost always a chance to stop, and ask for a few moments - maybe alone - to digest the change of plan that's been mooted.
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For example, if it's being suggested that a drip be set up because of slow progress. If medical help is being suggested at the point of delivery, which often does happen when mothers have an epidural, it can feel like there is less time - but it's still important to be proactive. For example, if ventouse is being suggested, to request that an episiotomy be avoided if that is your wish. Or if a baby isn't visible and still high, and you absolutely don't want forceps to be used, to have a caesarean.
Decisions would need to be made alongside the medical team caring for you, but engagement is key to feeling in control, unafraid and having good feeling about the birth afterwards.
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If a mother ends up in surgery, to have an unexpected caesarean, little things can make a really big difference. I am not allowed in - only one person accompanies, so that's usually the father. But I remind them as they go, to take a breath, to be present - babies arrive very quickly, surprisingly quickly once you are in surgery, and the moment can be missed with chat and all the buzz going on around you. If a mother has previously been in a very quiet, private birth room, all the activity can be distracting. So I might say a little parting word to remind them to stay together, for the partner to make sure he has a chair, very close to the mother.
What would make birth better for everyone?
If everyone clearly understood when a medical setting is necessary and when it is not.
The research and evidence has been repeating and repeating for years that for a healthy woman, with a healthy pregnancy, a standard, medical labour ward only increases the chance of a complicated birth. I think if people really understood this - I mean really - birth experiences would improve instantly. Those with complex pregnancies, who need medical support to be there and on hand, would know they are in the right place and be glad of the amazing obstetric facilities and service that we currently have. And women who had straightforward pregnancies, would also have appropriate care - mostly at home - they would also know they are in a place that is appropriate, a setting which gives them the best chance of anywhere of having a completely simple experience.
Given 75% of women say they want midwife led care, which in turns means they want nature to take it's course, having a setting that gives them the best chance of that would obviously be ideal and revolutionising. Overnight, we'd be rid of all the self-blame, confusion and disappointment our culture is permeated with around birth. We'd stop seeing birth as some kind of test for each individual woman to pass - women would stop feeling fearful that they won't cope, and we'd start approaching birth as we do other normal functions of the human body - providing women with the setting and care that's appropriate to get on with it. My book Why Home Birth Matters talks about this a lot!
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