Supporting Women to Give Birth at Home

A Practical Guide for Midwives

Mary Steen, Mary Steen

• Publisher: Routledge
• Year: 2012
• ISBN:
  9781136595820
• Edition: 1
• Topic: Medicina
• Subtopic: Ginecologia e ostetricia

Supporting Women to Give Birth at Home describes and discusses the main challenges and issues that midwives and maternity services encounter when preparing for and attending a home birth. To ensure that a home birth is a real option for women, midwives need to be able to believe in a woman's ability to give birth at home and to promote this birth option, providing evidence-based information about benefits and risks.

This practical guide will help midwives to have the necessary skills, resources and confidence to support homebirth. The book includes:

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• the present birth choices a woman has

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• the implications homebirth has upon midwifery practice

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• how midwives can prepare and support women and their families

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• the midwife's role and responsibilities

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• national and local policies, guidelines and available resources

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• pain management options

With a range of recent home birth case studies brought together in the final chapter, this accessible text provides a valuable insight into those considering homebirth. Supporting Women to Give Birth at Home will be of interest to students studying issues around normal birth and will be an important resource for clinically based midwives, in particular community based midwives, home birth midwifery teams, independent midwives, and all who are interested in homebirth as a genuine choice.

Chapter 1	History of Homebirth
	Jane Harris

• Introduction
• In the beginning
• The changing face of birth
• The medical culture of birth
• The technocratic approach to birth
• Conclusion
• References

Introduction

This chapter outlines the origins of midwifery and describes how homebirth was the norm for millennia. It explores the impact that medicine has had on childbirth, particularly as it has grown in strength and influence over the past 400 years. Looking at more recent developments, the chapter notes the social, professional, political and technological pressures that moved birth into hospitals as well as the recent resurgence of interest in homebirth. By exploring how homebirth came to be considered ‘dangerous’, the chapter helps the reader to see that it is not, and to understand how it can be rehabilitated.

In the home setting … the rhythms of a labouring woman’s body are honoured and waited on, and where birth is non-interventionist and centred on people, instead of mechanical processes.

Kitzinger (2002, p. 8)

In the Beginning

Life has a tendency to run in cycles, and we are now witnessing a more natural approach to all aspects of life from birth to the environment. Traditionally, throughout history, birth has been a social event that takes place within the nurturing setting of the home, which was the centre of life and where everything happened (Chamberlain et al., 1997). The event of birth was a communal celebration, a rite of passage (Van Gennep, 2004), with a predominantly female support mechanism (Donnison, 1988).

This approach worked fairly successfully for centuries in the main (Donnison, 1988). Mortality was high across the social and gender spectrum, with life expectancy in general being relatively low. Thus, high mortality rates in females were not only associated with childbirth (Gélis, 1991). Traditionally females have been the main carers in labour, with documentation of trained Hebrew midwives in the bible. In the Book of Genesis (King James Version, 35:16) it is stated that during the birthing process of Benjamin, the midwife told Rachel that she would have a son. This birth took place in or around 1800 BC and unfortunately Rachel did not survive. From a historical perspective the Bible is and remains a valuable source of recorded births and deaths including maternal mortality. Within Egyptian society midwifery was recognised as a female occupation of high standing, and this included attending and supporting the members of the royal households (Towler and Bramall, 1986). Documented scenes of Egyptian childbirth and midwifery support have been preserved in time from as early as 1900 BC (Gélis, 1991).

Midwives in Greece were held in high repute within the hierarchy of their early medical systems. Both the mother of Socrates and the wife of Pericles were midwives. The great scholar Aristotle spoke of the wisdom and intelligence of the midwives of Greece (College of Midwives, 2008). Within the system at that time midwives were categorised into two grades: those who were deemed to have a higher level of skill and knowledge, who were mainly responsible for women experiencing complicated labours, and those who assisted at normal births (Towler and Bramall, 1986). A parallel exists between practice in ancient times and the roles of midwives today in westernised societies, which has seen the increasing development of advanced midwifery practitioners who carry out instrumental deliveries and diagnose complications within the context of the hospital environment, working alongside midwives who remain the gatekeepers of normal birth (Walsh, 2007).

As medicine advanced within Greece during the next two centuries up to 300 BC, the demise of the midwife took place, much to the dismay of the women of Greece, who had strong objections to male attendants. It is apparent that as soon as medics take an interest in childbirth, they have great difficulty in working alongside the original practitioners of this art, the midwives. In response, one woman, Agnodice, disguised herself as a man in order to train under a famous physician and anatomist named Hierophilus. She did, however, reveal her true identity to the women she assisted and eventually she was denounced by the medical profession and was charged, although the mothers of Athens called for clemency. As a result, it was ruled that ‘three of the sex should practise this art in Athens’ (Potter, 1764). The voice of the client has always been a powerful force within the history of childbirth and in particular homebirth (Kitzinger, 2008).

Midwives have even been immortalised as gods in both Greek and Roman lore. Artemis was a goddess associated with childbirth, as was Hera the wife of Zeus. Hera was also recognised in Roman mythology under her Roman name of Juno Lucina. She was the symbol of the Roman matron, and women would call out to her in labour ‘Juno Lucina, ser opem’ (help assist the labour) (Towler and Bramall, 1986). The symbol on the hat badge of midwives in the UK is Juno Lucina holding a baby. This represents an educated and skilled woman from a culture and time when a midwife was a symbol of status within that society (McMaster, 1912).

Symbolism plays a major role in history and its interpretation, as does the status of women. It is clear that throughout history women have been encouraged to be educated and resourceful only when it is deemed necessary by the strong patriarchal force that has always been dominant and embedded within the majority of societies around the world (Pilley Edwards, 2005). The development of capitalism, industrialisation and professionalism led to greater benefits for men than for women. This then ensured that policy-making was led by men and therefore the needs of women became secondary. It is in this context that the history of birth, and in particular homebirth, has developed (Pilley Edwards, 2005). What has become obvious over time is that the picture of childbirth greatly altered as soon as medicine decided to create a specialised role within this previously female dominated forum (Donnison, 1988). Yet again this links closely with the long history of men controlling women.

The Changing Face of Birth

The stronghold of the home environment for birth was perpetuated throughout the Middle Ages, medieval times, the Renaissance, through to the early eighteenth century, even though hospitals became established institutions during this time. Their first incarnation was as a place where the poor were cared for, along with the dying and people who had suffered accidents, and this had connotations of death. Birth was perceived as a natural element of life and was not categorised as an illness requiring hospital treatment (Towler and Bramall, 1986).

The medical profession was developing and growing in strength, particularly within the specialist fields of surgery and medicine. Because of this growth, midwives were left alone to carry on with their work in the domain of childbirth. It is a incorrect to suggest that all midwives were uneducated and unskilled in their field. Even the traditional midwives were given training via the apprentice approach, whereby family members would pass down the skills and their teachings mainly based upon their experiences (Gélis, 1991). The majority of midwives gave the women the best possible care for that time in history (Gélis, 1991).

The more educated women who practised midwifery wanted to ensure that the role of the midwife developed and that the teaching of the skills and diagnostics was made more formal so that midwives could be monitored and regulated. Jane Sharp was the first English midwife to write a textbook on midwifery, in 1671. It was titled The Midwives Book or the Whole Art of Midwifery Discovered (Sharp, 1671). The purpose of the book was to instruct midwives to ensure that women were cared for by skilled attendants, which was in sharp contrast to the image of midwives during this period (Bosanquet, 2009). She strongly believed that a woman should be given individualised care and recommended mobilisation with the woman taking up the positions that her body dictated; this was in contrast to the views of male authors of the time, who prescribed that only certain positions be used for birth. The issues of advocacy, accountability and partnerships in care were documented and championed by Sharp. Also included in the book was a series of drawings showing fetal positions, advice about all stages of labour and the importance of nutrition and hydration during labour.

The Church played a major role in demonising midwives and the services that they had to offer the communities in which they lived. This stemmed from man’s intrigue with birth and its links to procreation. The Church became judicial in relation to governing the practices of midwifery, stating that women who could become a midwife must ‘be of good character’ (Towler and Bramall, 1986) This premise has been carried on to the present day as in order to register as a midwife the lead for midwifery education must sign a declaration of good character for each student at the end of the programme of education (Nursing and Midwifery Council, 2009).

Medicine’s fascination with birth really came into play during the eighteenth century, which saw the emergence of the man-midwife, an early incarnation of the obstetrician. The Chamberlain brothers devised a set of forceps for assisting difficult births within the home environment, and William Smellie attended several homebirths and commented on the use of birthing stools and the left lateral position when using the bed. He concurred that both positions were very helpful in assisting women through the process of birth (Towler and Bramall, 1986). Middle- and upper-class women were willing to pay for the services of the new man-midwife because they perceived a trained male as superior to a midwife. This view is reflective of the status of women during these times, predominantly uneducated in a formal sense with no voting rights and no real social rights (Towler and Bramall, 1986). The historian Don Shelton’s recent revelation (Shelton, 2010) about the pregnant women used as models for the anatomical atlases produced by William Smellie and William Hunter is enlightening. He posits that these women were procured through the practice of ‘burking’, that is, soliciting the murder of people for medical investigation. This highlights yet again the fact that women and their bodies were perceived as vessels for unlawful and unethical experimentation and professional gain by some medical men, such as William Smellie.

Whilst Smellie was assisting in and writing about homebirths, maternity hospitals were being opened in western Europe. They were mainly established by philanthropists who deemed that the poor and lower classes did not live in the right conditions for home deliveries and consequently they established lying-in hospitals. This act was mainly for charitable and social reasons rather than being based on medical evidence. From 1739 to 1765 four of these institutions were established in London. Only one of the original lying-in hospitals remains open today, and that is Queen Charlotte’s Hospital for Women. This type of hospital was also being established in Dublin (the Rotunda Maternity Hospital) and in Edinburgh (Towler and Bramall, 1986). Some of these establishments provided short training periods for female pupils. They were trained and examined by doctors, and this continued until the twentieth century (Cowell and Wainwright, 1981). It would seem that a body of women who were trained and deemed competent practitioners were believed to be unable to govern their profession in an accountable way. The picture that is usually presented of midwives at this time is of a motley crew of uneducated, unclean and drunken women from the poorest backgrounds, but this was not the case. Many of the midwives had received a formal education and had then undertaken training to become a midwife. The care they provided was of a standard that was appropriate at that period in time (Donnison, 1988). The influence of medicine was already having an impact on the development of midwifery and the power battle between midwives and the developing specialty that was to become obstetrics had begun. These developments had a growing impact upon midwives practising their art as they struggled to compete with their male counterparts. They persevered and, by the end of the eighteenth century, midwifery had survived (Donnison, 1988).

Maternity hospitals were not a new concept in Europe. Major cities in France and Germany had maternity hospitals that had been established since the middle of the sixteenth century; however, they were not particularly popular with the women of the day. One of the most famous and earliest maternity hospitals was the Hotel Dieu in Paris. It was mainly a teaching establishment, where the poor of the city were gathered so that Ambroise Paré could train midwives (Towler and Bramall, 1986).

In the nineteenth century, 15 additional maternity hospitals were established in the UK, mainly in the highly populated cities. The majority of women, 99 per cent of whom had uncomplicated pregnancies, were still giving birth at home (Campbell and Macfarlane, 1995), which was safer because rates of puerperal sepsis leading to maternal mortality were increasing in the maternity hospitals (Towler and Bramall, 1986). Infection was transferred from patient to patient via the unwashed hands of the carers, in particular by doctors, who not uncommonly carried out postmortem examinations and then performed internal examinations upon the women without washing their hands. The answer was simple – increase the levels of hygiene, which meant hand washing between patients and procedures. This simple task reduced the incidence of infection and is still the main bulwark against cross-infection today (Johnson and Taylor, 2010).

The Medical Culture of Birth

During the nineteenth century major developments took place within the realm of maternity care. They were the use of chloroform for the relief of pain in labour, as used by Queen Victoria, and the increasing success of caesarean sections as life-saving operations. These developments were costly and were carried out in the hospital environment, which meant that they had little impact upon domiciliary midwifery and poorer women (Towler and Bramall, 1986).

As the legislation and governing of medicine was developing, so too was the issue of the status of the midwife. Florence Nightingale supported the traditional premise of midwifery, but she also wanted to extend the role and raise the standard of practice by ensuring that the right kind of women entered the profession and that they were trained to give a high level of skilful care (Nightingale, 1871). From the late nineteenth century, many educated women practised as midwives and they wanted to ensure that the profession became self-governing with a legislative foundation. A small group of midwives led by Miss Zepherina Veitch and Rosalind Paget began the Midwives Institute and petitioned parliament to endorse and pass the Midwives Act. It was not an easy process and it took perseverance to finally get the Act through in 1902. The Act set up the Central Midwives Board, which was the governing body for all trained midwives. From this came the midwives’ rules, which set out the standards and the parameters of practice. This was a major development for the profession but it was tainted by the dominance of the medical presence surrounding the changes (Cowell and Wainwright, 1981).

During the early part of the twentieth century, midwives were still self-employed and their income was dependent on what women could afford to pay for their services; furthermore, payment was not always in a monetary form. Also during this period antenatal care and the precursor of antenatal education were introduced in Scotland. The benefits of this care were disseminated and the programme was rolled out across the UK. Alongside these new developments in maternity care, the rate of maternal mortality was causing the growing number of obstetricians concern. From 1869 to 1900, the recorded maternal mortality rate was 5.5 per 1000 live births and the average infant mortality rate was 153 per 1000 live births. The reasons for high mortality rates were poverty, unsanitary living conditions, high fertility rates and poor nutrition leading ...