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Warm births
Every day more women opt to give birth more naturally
by Paloma Arenos
La Vanguardia 25/06/2006
Being born gets safer by the day in Spain. In each new pregnancy numerous tests and ultrascans are carried out that give information about the state of the fetus, discover its sex and prevent many illnesses. All this for the wellbeing of the mother and the baby. But, technical advances have taken the emphasis away from the woman. The last three decades have seen what many specialists have named medicalisation of the pregnancy and birth process. According to some groups dedicated to caring for pregnant women and newborn babies, the obstetric advances have not just brought benefits.
On the other side of the coin is the excessive standardisation of care and services, detached and pressured treatment, and the carrying out of interventions that could be avoided in low risk births, such as episiotomies, inducing of contractions through medication and restricting the woman's movement.
The excess of technology to the detriment of caring, individualised treatment leads some couples to look for a warmer way to receive their child. Maternity homes, hospitals with a natural birth protocol in place and homebirths attended by health professionals are three of the most requested alternatives.
One year ago Mónica Pareja and her husband Oriol, residents of Caldes d'Estrac (Maresme) joined this personal debate. They were expecting their second child, five years after the birth of their daughter Savina. Mónica is 34 and employed in a textile workshop in Barcelona, a lively woman who believes that "birth must be as respectful as possible with the rhythms of nature, but without forgetting technology when it's necessary for saving lives". In fact, she gave birth to Savina at home, accompanied by her partner and backed by a team of midwives they had hired.
No epidural or continual internal examinations nor pressure from medical staff, but with all her inner strength, patience, tenderness and lots of breathing and physical endurance to overcome the pain and the long wait, Monica received her first daughter with Oriol's help in the warmth of their home. After over 24 hours of labour, the mother was exhausted. "Since the post natal recuperation was so long and painful Oriol asked me to go to a hospital for the next birth so that they could take care of me after the birth" - she explains. "In accordance with our lifestyle, we decided to find a centre that procures the most natural birth possible and that would respect my rhythm, without rushing me through, as though on a production line."
She found what she was looking for at Barcelona's Maternitat hospital, the only public hospital in the province of Barcelona that has pushed forward a protocol that defends natural birth. Both doctor and birthing mother must sign the document to guarantee that, as long as there are no complications for the fetus or the mother, there is as little intervention as possible, and that the emphasis is on the woman, not the doctor. For natural birth the Maternitat offers a birthing room with a bed with adjustable sections and a birthing chair where the woman can give birth in a squatting position rather than lying down. The medical staff encourage the woman to walk to facilitate dilation and encourage her to relax her lower back and pelvis by sitting on a large ball. The objective, so long as there is no emergency, is to respect the rhythm of the birth, and routine enemas and pubic shaving are avoided.
Doctor Vicenç Cararach, who recently retired after 15 years as head of gynecology at Barcelona's Hospital Clinic, created this innovative protocol in 1996 and, taking advantage of the fact that the Maternitat was taking over the Clínic's births, took the protocol there in 2000. There are now about ten hospitals throughout Spain, mostly in Catalunya, that have been inspired by this model and that are beginning to apply it. "Here, we let the woman move around, walk, bring her own music and be accompanied by her partner, but always under medical supervision" explains Glòria Sebastià, the head midwife. "In order to offer the level of personal care that we would like to we need the authorities to ensure that there enough midwives trained in natural birth on duty at all times." Cararach claims.
Although it's still only a minority of women that want a physiological birth in Spain, consulted experts confirm that demand is rising. The association Nacer en Casa, founded in 1988 and made up of some 20 gynecologists and midwives from all over Spain, confirms that approximately one percent of Spanish women have a homebirth attended by health professionals. Yet, in countries such as Holland, Sweden and the United Kingdom, the figure rises to 30%, and these births are covered by the social security.
In 2003 the Generalitat de Catalunya designed a protocol for birth assistance that, among other things, commits to limiting caesareans exclusively to necessary cases and states that health centres must be sensitive to offering women the kind of birth that they want. Referring to low risk births, Cararach insists that his medical colleagues must "let the woman choose what she wants. If we can't treat pregnant women more with more care in hospital, they'll end up giving birth at home and that is much more dangerous."
Midwife Pepi Dominguez, of the cooperative Titània-Tascó of Barcelona, which has been a pioneer of homebirths in Spain for 20 years, says that "the woman who opts for a homebirth does so after a great deal of reflection and after preparing herself both physically and mentally. We defend science and technology when it is necessary, but when it's a low risk birth it's a question of giving the woman freedom in a calm place where she feels comfortable".
The private teams who attend homebirths - normally made up of two midwives, and ocasionally a gynecologist - only accept low risk pregnancies, and so exclude cases that could be problematic for mother or baby, such as the birth of twins, a breech birth or if the mother has high blood pressure. Antenatal care, as in any other pregnancy, is meticulous. The home must also be near a hospital in case of any emergency, preferably no longer than a 10-minute drive away. This drive to hospital with the vital loss of time for the mother or baby's health is one of the most common fears of those who dismiss this option. However, Nacer en Casa is not afraid of showing the statistics. Since 1998, 1,450 homebirths have been attended, of which 242 ended up being taken to hospital for health complications for the mother or baby, which is equivalent to a transfer rate of 16.6%. But, giving birth at home still provokes a lot of social rejection and most of the medical profession considers it to be an imprudent return to the past.
The president of the Spanish Society of Gynecology and Obstetry (SEGO), gynecologist José Manuel Bajo, is of the opinion that "if the alternative of homebirth is still a minority option and is not increasing that is because of its limitations and because women are well informed and do not accept risks." Bajo describes the professionals that attend this type of birth as kamikazes and says that they must be "ready to accept the penal consequences of possible complications".
In the light of these considerations, Doctor Cararach believes that the challenge facing the Spanish public health system is for "the woman to be attended in hospital as though she were at home. She must feel comfortable, but without compromising at all on the level of technology". For Cararach, "the technology does not have to be on show because at times its appearance can cause a negative impact on the woman and bring labour to a halt".
This is an idea that the French obstetrician Michel Odent proposed back in 1962 when he was made head surgeon in the public hospital of Pithviers. The hospital had a small maternity ward of two midwives who called him in to help with difficult cases. Odent realised that "women were very inhibited when they arrived to give birth in the hospital. And since this slowed down the birth, little by little we brought home to the hospital. We converted a birthing room into a living room, without any medical equipment visible", he remembers.
This author of 11 books, translated into 20 languages, affirms that "when giving birth, the woman secretes a cocktail of love hormones, of which the most important is oxytocin. But these days most women give birth without having secreted this cocktail as they are given medication that blocks the secretion". From that perspective he defends the most natural form of birth possible, without external agressions, because "how we are born affects us for the rest of our lives".
And, it was in this situation that Mónica found herself last year. To pass the ultimate challenge with flying colours, she followed the antenatal classes for natural birth at the Maternitat, given by Glòria Sebastià, and which cover breathing control (very focussed on the strengthening of the perineum), and mental techniques (relaxation, visualisation, breathing control). On the night of July 29 her waters broke at home. In the hospital they told her that she couldn't go out for risk of infection, but in the end, seeing that it was going to be a long wait, the couple managed to go out for a walk. "Mobility helps to bring on contractions and get labour started", advises midwife Dominguez.
Once inside, Mónica spent many hours in the natural birth room with Oriol encouraging her and giving her massages to lessen the pain. Her parents and Savina arrived at the hospital on the morning of July 30. After the long wait, she was at last attended by Cruz, a midwife who defends natural birth and who "helped me at all times, was respectful of my wishes and always consulted me. She made me feel comforted." As Monica was not dilating, in the end they applied synthetic oxytocin. The contractions still didn't progress and she was exhausted. She remembers that a nurse tried to shave her pubic hair but she stopped her. Tired and tearful because it would just not end, she decided to ask for an epidural. Within a short time she had recovered her spirits. "I just felt bad not feeling my son, as though I had abandoned him, but the birth was wonderful, because Cruz brought me a mirror and I could see Gerard come out", she remembers, still moved by it.
She did everything she could to give birth without anaesthetics but in the end it just wasn't to be and she has no regrets. "During the whole pregnancy, the antental preparation and the birth, they gave me the respect I was looking for. I felt well treated".
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