Fish Can't See Water

Click here to read the full article: Fish Can't See Water

Marsden Wagner is simply an international Normal Birth god. He began his career in public health as a neonatologist and epidemiologist, firstly in California then Denmark. He retired from a distinguished career as Head of Maternal and Child Health for the European Office of the World Health Organisation (WHO), he now acts as a consultant for WHO in the emerging countries of central and eastern Europe. Marsden Wagner chaired the three consensus conferences convened by WHO on appropriate technology around the time of birth and is in demand as an international speaker for his forthright support of midwifery and midwives.

Just a little bit qualified to talk about women & birth then......

Fish Can't See Water - the need to humanise birth - is an article Marsden wrote for the International Journal of Gynaecology & Obstetrics & is relevant to birth throughout the western world. It's a pretty long piece of writing, so you may want to leave it until your lunch hour, or print it out & read chunks at your leisure.

But I do urge you to read it asap as it will open your eyes to why the medical profession is lost in such a hopeless fog when it comes to childbirth.

Reading this article is very empowering & it will give you a good grounding in most of the issues as to why birth is so hideous for so many western women. He's written lots of other brilliant artciles, but I've listed them under Routine Tests & Interventions on this website.

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IN BRIEF:

For those of you who can't be bothered to plough through Marsden's excellent work (shame on you), his main points are:

Birth in the West has become dehumanized because fish can't see the water they swim in - that is, birth attendants, be they doctors, midwives or nurses, who have experienced only hospital based, high interventionist, medicalised birth cannot see the profound effect their interventions are having on the birth. These hospital birth attendants have no idea what a birth looks like without all the interventions, a birth which is not dehumanized.
Even the WHO agrees: "By medicalising birth, i.e. separating a woman from her own environment and surrounding her with strange people using strange machines to do strange things to her in an effort to assist her, the woman's state of mind and body is so altered that her way of carrying through this intimate act must also be altered and the state of the baby born must equally be altered. The result it that it is no longer possible to know what births would have been like before these manipulations. Most health care providers no longer know what 'non-medicalised' birth is. The entire modern obstetric and neonatological literature is essentially based on observations of 'medicalised' birth."
Medicalised birth is dehumanizing because the doctor is always in control, not the woman
Labour and birth are functions of the autonomic nervous system and are therefore out of conscience control. Consequently there are, in principle, two approaches to assisting at birth: work with the woman to facilitate her own autonomic responses - humanized birth; or override biology and superimpose external control using interventions such as drugs and surgical procedures - medicalised birth.
Today prevalent medical opinion is that 'modern', i.e. Western obstetric-intensive maternity care saves lives and is part of development and attempts to bring maternity care excesses under control are retrogressive. The present situation in developing countries reinforces the idea that the only reason out-of-hospital, midwife intensive birth still exists in places is because modern medical practice is not yet available.
We override biology at our peril. For example, if we stop using our bodies, they go wrong. It is 'modern' to get around in a car or public transport resulting in little walking much less running. Then science finds out that our bodies need such exercise or we get cardiovascular problems. So today the post-modern idea is to go back to walking and running (jogging) and this is seen as progressive, not retrogressive. By the same token, humanizing maternity services is not retrogressive but post-modern and progressive.
The negative effects of development on maternal mortality are also emerging. Obstetric interventions such as caesarian section sometimes save lives and sometimes kills - maternal mortality even for elective (non-emergency) caesarian section is 2.84 fold or nearly three times higher than for vaginal birth.
We are now at the point in maternity care in industrialized countries where the positive effects of development and technology are approaching the maximum and the negative effects are surfacing. This helps to explain why advances in technology and in development cannot lead to improvements in health unless the technology is in harmony with natural biological processes and is accompanied by humanized health care.
Obstetricians, like all clinicians, work hard to help one patient at a time. In balancing efficacy and risks, doctors desire to help puts the focus on efficacy rather than risks, resulting in a number of examples of interventions which went into widespread use before adequate scientific evaluation. Prenatal X-ray pelvimetry in the 1930s, di-ethyl-stillbesterol (DES) for pregnant women in the 1950s and thalidomide for pregnant women in the 1970s are examples of obstetric interventions which have had tragic consequences because they went into widespread use before adequate scientific evaluation.
Behind these misunderstandings in interpreting scientific data is the reality that most practicing doctors have little or no training in science. Furthermore, there is a fundamental difference between the practice of science and the practice of medicine. To generate hypotheses, scientists must believe they don't know while practicing doctors, to have the confidence to make life and death decisions, must believe they do know.
The one approach clinicians can understand is single case, anecdotal evidence. This approach leads to the 'what if' scenario in which applying population data to their practices is rejected by clinicians because 'what if' this or that goes wrong with an individual patient. There is no better example of this than planned out-of-hospital birth.
Many clinicians and their organizations continue to believe in the dangers of planned out-of-hospital birth, either in a birth center or at home, rejecting the overwhelming evidence that planned out-of-hospital birth for low risk women is safe. The clinician's response to this evidence is "But what if there is an out-of-hospital birth and something happens?" Since most clinicians have never attended an out-of-hospital birth, their 'what if' question contains several false assumptions. The first assumption is that in birth things happen fast. In fact, with very few exceptions, things happen slowly during labour and birth and a true emergency when seconds count is extremely rare and, as we will see below, often in these cases the midwife in the birth center or home can take care of the emergency.
The second false assumption, that when trouble develops there is nothing an out-of-hospital midwife can do, can only be made by someone who has never observed midwives at out-of-hospital births. A trained midwife can anticipate trouble and usually prevent it from happening in the first place as she is providing constant one-on-one care to the birthing woman, unlike in the hospital where usually nurses or midwives can only look in occasionally on the several women in labour for which they are responsible.
The third false assumption is there can be faster action in the hospital. The truth is that in private care the woman's doctor often is not even in the hospital most of the time during her labour and must be called in by the nurse when trouble develops. The doctor 'transport time' is as much as the 'transport time' of a woman having a birth center or home birth. Even when a caesarian section is indicated, it takes on average 20 minutes for the hospital to set up for surgery, locate the anesthesiologist, etc. and during this 20 minutes either the doctor or the birth center or home birthing woman are in transit to the hospital.
These are the reasons there are no data whatsoever to support the single case, anecdotal 'what if' scenario used by some doctors to scare the public and politicians about out-of-hospital birth.
Although obstetric care is gradually becoming more evidence based, there is a tendency not to evaluate obstetric interventions for their subtle and/or long term risks. For example, evidence suggests an increasing incidence of certain neurological problems such as attention deficit disorder, dyslexia and autism. While attempts are being made to find causes for these problems, I know of no attempt to determine any correlation's with simultaneously increasing obstetric interventions such as prenatal ultrasound scanning, pharmacological labour induction, epidural block for normal labour pain, elective CS.
Another reason for the gap between evidence and practice is the excuses often given by physicians for why they reject evidence in their medical practice. These excuses include: the evidence is out of date; collecting evidence is too slow and prevents progress; I use clinical judgment and my experience; using anecdotal 'horror stories' to try to prove the need for an intervention which the evidence has found unnecessary; quoting evidence which is of poor and/or inadequate quality; 'trust me, I am a doctor'; 'stop doctor-bashing'; evidence erodes physician autonomy. In addition to these excuses, in maternity care common excuses include: our women have smaller pelvises (no evidence), our babies are getting bigger (no evidence), our population is not as homogenous (no evidence).
The quintessential example of medicalisation and dehumanization of birth is unnecessary caesarian section (CS) in which the surgeon is in charge and the woman no longer has any control. CS saves lives but there is no evidence that rising CS rates the past two decades in many countries has improved birth outcomes.
Why so much unnecessary CS? When maternity care is controlled by doctors and midwives are marginalised or absent, higher CS rates are found. Many studies have shown lower obstetric intervention rates when midwives attend low risk birth than when doctors are providing primary birth care to low risk women. Having a highly trained gynecological surgeon attend a normal birth is analogous to having a pediatric surgeon baby-sit a normal two-year old child. It would be a waste of the pediatric surgeon's time and skills and, when the young child gets tired and fussy, the surgeon might be tempted inappropriately to use drugs, where a properly trained baby-sitter would soothe the baby with a variety of non-medical techniques---the medicalisation of normal childhood similar to the medicalisation of normal birth. High CS rates are a symbol of the lack of humanization of birth.
While many obstetricians are prone to ask "Is home birth safe?", a more appropriate and urgent question is: "Is hospital birth safe?".
At least 80% of all women are capable of a normal birth without intervention but among low-risk Australia women having their first birth in private hospitals only 18% are judged by doctors as capable of a normal birth without serious intervention. Over half of low-risk Australian women having their first baby are judged by doctors as incapable of initiating their own labour: 47% of low-risk primips in private hospitals in Australia have spontaneous labour. These figures are truly shocking.
To understand why there is now an epidemic of epidural block for normal labour pain, it is necessary to understand what happens to the woman before she is offered the epidural. The care she receives when she comes to the hospital to give birth markedly increases the pain she will have. Scientific evidence shows labour pain is significantly increased: by laboring in an unfamiliar place; by being surrounded with unfamiliar people; by having unfamiliar procedures done; by being left unattended during labour; by being put in a horizontal position and not allowed to freely walk about; by having the membranes artificially ruptured; by having induction or augmentation with drugs. So the woman comes into the hospital in labour, has a number of things done which all increase her pain, is then offered an epidural and is so grateful to the staff for the relief of the pain, much of which the staff created.
Is epidural block safe? The single most important new trend in modern obstetrics is a universally agreed principle that all obstetric practice must be based on the best scientific evidence. What is the evidence on the safety of epidural block? First, a procedure can hardly be called 'safe' when close to a quarter (23%) of women receiving epidural block have complications. The risks to the woman are many and serious, starting with the possibility the woman will die because of the epidural. The maternal death rate for women having epidural block for normal labour pain is three times higher than for women with normal labour not having the block. For every 500 epidurals performed there will be one case of temporary paralysis of the woman and the paralysis will be permanent in one of every half million epidurals. The woman has a fifteen to twenty percent chance of fever after receiving an epidural, necessitating a diagnostic evaluation for possible infection in the woman and baby which can sometimes be invasive such as requiring a spinal tap of the baby. Between fifteen and thirty five percent of women given an epidural will suffer from urinary retention after the birth.
How effective is epidural block in relieving pain? In around 10% of epidural blocks it doesn't work and there is no pain relief. Even when it works, around a third of women given an epidural will trade a few hours of pain-free labour for days or weeks of pain after the birth. Thirty to forty percent of women receiving an epidural during labour will have severe backs pain after the birth and 20% will still have back pain a year later.
There are several strategies for humanization of birth - strategies which will put the woman and the family back in control of the birth of their own child while empowering the woman to believe in herself through experiencing what her own body can accomplish.
The first strategy is education. Those who control information hold the power. In the past the medical profession has maintained control of medical care through protecting and withholding information. The information revolution is profoundly changing medical care. The advent of the internet and world wide web is having a profound effect on bringing medical information to everyone. In the new millenium a global movement is demanding accountable and transparent health care practitioners and health care facilities (including hospitals) as a basic requirement of any democracy.
A second strategy for humanization of birth is the promotion of evidence based maternity care practices. As mentioned earlier, using peer review and community standards of practice has failed to close the gap between present obstetric practices and the evidence. And in many places public health professionals and government agencies have failed to aggressively pursue closing the gap between obstetric practices and evidence, often out of fear of the power of the medical establishment.
Another essential strategy in humanizing birth is: who is the primary care giver for women during pregnancy and birth. The tradition of doctors insisting on controlling their own practices with little or no interference from the community or its representatives goes back a long time. During the course of the twentieth century, the practice of doctors going on 'house calls' disappeared for good reason---doctors are uncomfortable in the patient's home as the family is in control. As long as doctors provide primary care to normal, healthy pregnant and birthing women, women will not be in control and humanization of maternity care will not happen.
In order to maintain their hegemony over midwives, doctors attack midwives, especially midwives in independent practice where they are not under the control of doctors or hospitals. The past two decades has seen a global witch hunt of midwives.
Because of the frightening propaganda of the obstetrical profession about how dangerous birth is, many women want the freedom to control their own birthing but need the 'security' of an institution. How can women today be in control of giving birth and be empowered by birth and be assisted by a midwife and still feel comfortable and protected by an institution? By choosing an alternative birth center (ABC) which is 'free-standing' (i.e. out-of-hospital) and staffed by midwives.
The type of care provided in an ABC is quite different from a hospital. In a hospital the doctor is always in absolute control while in an ABC the woman is in control. In the hospital the emphasis is on routines while in the ABC the emphasis is on individuality and informed choice. Hospital protocols are designed with all the possible complications in mind while ABC protocols focus on normality, screening and observation. In hospitals pain is define as an evil to be stamped out with drugs while in the ABC it is understood that labour pain has a physiological function and can be relieved with scientifically proven, non-pharmacological methods such as immersion in water, changing position and moving about, massage, presence of family, continuous presence of the same birth attendant.
Compared to hospital births, home births and births in ABC's are safe, much cheaper, use far less unnecessary interventions, are more satisfying to the woman and family. In other words, out-of-hospital birth is an important strategy in humanizing birth care.
The final solution is to evolve new social and political forms for the medical profession and for medical care. Maternity care needs turning around so that, instead of drifting away from physiology and from the social and cultural environment, the process moves toward respecting and working with nature and with the woman and family, turning control of medical care over to the people.
FOR THE FULL TEXT PLEASE GO TO FISH CAN'T SEE WATER - IT'S REALLY WORTH IT