Bridging the controversies
We are delighted that our book has reached the world of radical midwives. We have some concerns, however, about what appears to be selective reading. Sarah Montagu is more than happy to quote our criticism of technocratic obstetrics, but seems to close her mind from our criticism of unfounded dogmas in midwifery care. Both obstetricians and midwives will have to adapt to many changes if progress is to be made. Entrenched positions will not help to bridge the detrimental gap between these professional groups. Obstetricians and autonomous midwives should cease their destructive territorial struggles, place the labouring women first, base their practice on science and reliable evidence, value and respect their complementary skills, cooperate closely for the common good, and evaluate the satisfaction of their clients/patients with the labour experience, free from selection bias. These features form the very essence of our approach. Normal birth is a human right and proactive support of labour is the best way to achieve this.
Item by item:
1. Montagu states: The foreword calls the book a “critical counterbalance to technological interference in labour and delivery” – this seems an extraordinary way to sum up a book that assumes that no primigravid labour should last longer than twelve hours, as this presupposes technological interference. It is interesting that although the statistic of how many labours in the authors’ obstetric unit in the Netherlands are augmented with oxytocin is mentioned, buried deep in the text almost as an aside, it is not included in the table of data which would surely be as relevant a statistic as the rate of ‘spontaneous’ deliveries – unless oxytocin doesn’t count as a technological interference?!
Answer: There is no contradiction in insisting on physiology and the prevention of abnormally long labour. Early recognition and timely correction of dysfunctional labour is not about medicalising birth but about safeguarding and re-establishing physiology. Withholding timely and adequate treatment where it is clearly indicated is what makes women end up with traumatic labour experiences and caesarean deliveries. Apparently, Montagu regards selective use of oxytocin as a reprehensible “technological interference”, based on the unfounded assumption that most women do not desire minor “interventions” to prevent long labour. In reality, however, when honestly informed about likely scenarios, women with slow labour invariably prefer a proactive IV-line with oxytocin in their arm to a needle in their back, a vacuum-cup or forceps in their vagina, or a knife in their lower abdomen at a later stage. Early correction of slow labour does not lead to more interventions; rather the exact opposite is the case. Besides, we do not administer oxytocin more frequently than others, rather better timed and better dosed, and the great majority of women supervised according to the principles of proactive support of labour do not need oxytocin at all. The dogmatically expectant approach to slow labour, as advocated by Montagu, lacks any scientific basis and appears to be founded on atavistic ideology and territorial interests of midwives who eschew timely help from obstetricians, rather than on respecting the interests, preferences and needs of labouring women.
2. Montagu comments: But, and it is a huge but, if they are saying that they respect physiology, surely this extends to respecting the physiology of labour. Not all slow births are dysfunctional; they criticise the midwifery approach as a passive process of waiting out the first stage of labour where “the patience of birth attendants exceeds the stamina of a labouring woman” but ignore (or possibly have never come across?) births where patience is exactly what is needed.
Answer: Typically, Montagu elevates exceptional cases to the rule. Naturally, there are some women who tolerate long labour or in whom labour, when given the chance, will accelerate spontaneously after an initially slow onset. However, even radical midwives do not posses a crystal ball; a much more likely scenario - that we have come across all too often - is that the midwife’s patience will lead to an overly long labour, exhaustion, and related agony, resulting in physical and emotional trauma and operative delivery. Close attention to progress during the early hours of labour is the best insurance against difficulties later and key to a woman’s satisfaction with her labour experience.
3. Montagu concludes: Although the authors do state that it is crucial that every element of their approach, including the continuous one-to-one support, is used, it is clear those centres which introduced it and said it didn’t work, tended to ignore the one-to-one support and focussed on frequent vaginal examination, amniotomy and augmentation. This would lead one to conclude that the continuous support is a far more important and potent intervention than hustling every labour along to a strict timetable.
Answer: Sarah Montagu is correct. The other supportive elements – not only one-to-one support, but also clarity, honest information, keeping promises, positive psychology, effective coaching, etc – are far more important, but these crucial aspects of high quality care cannot be implemented unless effective prevention of prolonged labour is taken care of as well. The demanding requirements of non-stop presence, personal commitment and continuous emotional support extended to all women in labour are strongly dependent on a twelve hour limit on the maximum duration of labour. Work schedules exceeding twelve hours are unrealistic.
4. Montagu wonders: Although they acknowledge that labour is a parasympathetic process where any kind of stress can de-rail the flow of hormones required to allow physiology to unfold, they do not really acknowledge how that is compatible with hourly vaginal assessments in early labour and a continual focus on how the labouring woman is measuring up to the pre-set timetable.
Answer: Montagu is worried about the frequency of potentially “disruptive” vaginal examinations. However, the total number of VE’s in our practice - 3.7 times on average - is actually lower than in most conventional practices wherein slow, long labours are tolerated. It is exactly the clarity of the informed and consented birth-plan, the firm promise of short labour, the personal attention, and the reassuring attitude of all birth attendants that strongly promote the parasympathetic condition and ambiance needed for a physiological birth. Securing effective labour and keeping women regularly posted on their progress are prerequisites for positive coaching and a mark of respect for women. It has nothing to do with “hustling every labour along to a strict timetable” as Montagu dubs it.
5. Montagu accuses: The paternalism comes across loud and clear. Women are here obviously still subservient to the all-seeing and all-knowing health care professionals who are the only ones who can truly know what is happening in a woman’s body.
Answer: The reactionary attitude of radical midwives is sadly all too well founded on the many traumatising experiences of women with over-medicalised, impersonal, and technocratic hospital care. We share the same worries and that is exactly the reason why we wrote this book. As it is now, frustration, disappointment, and traumatisation have fueled fury, rancour, and distrust in doctors, and have even led to calls for “free birthing”, laying unbounded trust in the inborn powers of women who know best what is happening in their body. These trends - however understandable - will inevitably lead to outcomes similar to those in ancient times when all women underwent unassisted labour and delivery. This cannot be the intention. We better reform our obstetric practice combining the best of midwifery and medicine as pointed out in our book. The accusation of paternalism is therefore wide of the mark. Professionalism is the correct classification. All components of our approach are firmly based on biological science and reliable clinical evidence. We surely hope that all professional birth attendants, including radical midwives, do have more scientific knowledge about the biophysics and physiology of normal parturition than their lay clients do. When this is not the case, these caregivers will surely benefit from reading this book and that will doubtlessly benefit their clients/patients as well.
6. Montagu reproaches: They are also happy to make some swingeing criticisms of the Dutch independent midwifery system, but do not at any point appear to consider that one of the major problems is the huge caseloads that Dutch midwives carry (Wiegers 2007), which are surely more likely to be a crucial factor in the discontinuous care in the first stage of labour for home birth mothers than a lack of responsibility on the part of the midwives.
Answer: We are better informed, for sure, about the Dutch independent midwifery system than Sarah Montagu. The official norm is 105 intakes per midwife a year, meaning 2 potential home deliveries a week. However, more than 50% of their clients are being transferred during pregnancy or delivery to the secondary care echelon, leaving on average 1 delivery per week entirely completed under her care. It is not “this huge case load” that prevents Dutch midwives from continuous care in the first stage of labour for home birth mothers. Rather dogmatic tolerance of long labour and poor organisation is the real problem. Long labours are incompatible with continuous labour attendance, and other work obligations such as antenatal care and postpartum visits for other clients prevent them from sitting with their labouring clients during the entire labour as well. Captured in a catch-22 situation, Dutch midwives during their training are taught to leave their clients to their own devices for long hours. But whenever continuous labour attendance cannot be guaranteed, home birth becomes irresponsible. If you aren't there, you don't give care! Clearly, major changes in attitude and organisation are called for. Montagu completely disregards our proposals for organisational reforms that will enable midwives to stay with their labouring clients.
7. Montagu agrees: Although the authors point out the futility of induction prior to physiological readiness for labour, they do not really examine or propose what one should do when pregnancy extends beyond 42 or 43 weeks, apart from carrying out the inductions that are so clearly ineffective if the body is not ready.
Answer: Our strong plea for curtailing the use of labour induction does not mean that some conditions do not remain a valid indication, such as post-term pregnancy at 42 weeks. Waiting longer carries risks of inexcusable fetal demise and, equally relevant, waiting longer does not result in fewer interventions. In spontaneous labours beyond 42 weeks the caesarean rate equals or even exceeds the caesarean rate for failed inductions at 42 weeks, owing to fetal distress, heavy meconium passage, and dystocia. Pregnancies beyond 42 weeks are not physiological, and post-term labours are not physiological. Even radical midwives should accept this.
8. Montagu says: They also follow O’Driscoll in rejecting the idea of a latent stage of labour, but do not offer any kind of way of helping or validating the experience of those women who have the temerity to say they are ‘in labour’ before they fulfil the doctors’ criteria, apart from sedation or sending them away.
Answer: Apparently, Montagu belongs to the category of providers who pretend to be able to coach women through labour without clearly identifying the onset of this exertion and without regular assessments of its progress. Our critic missed some important points. In fact, our book is one of the very few that devote a separate and comprehensive chapter to the diagnosis of labour and the effective prevention and treatment of false labour.
9. Montagu states: It also seems extraordinary completely to ignore the third stage of labour – if the authors can say ‘it is the sum of the parts that make the system work’, and if they advocate a system which predicates a liberal policy of exogenous oxytocic supplementation, they should surely pay at least some attention to the effect this might have on the third stage.
Answer: We do not ignore the third stage of labour as Montagu states. We only excluded the third stage of labour (for practical reasons) in the definition of labour duration. By the way, third stage haemorrhage occurs more often in women with a depleted uterus after an overly long labour.
10. Montagu is annoyed: As a minor point, I have to say that I found the continued repetition of proactive support of labour in italics as the panacea to all ills in the maternity services rather irritating and rather reminiscent of the tone of Victorian advertisements for patent medicines – if they are so convinced of the efficacy of the method, it shouldn’t need that kind of stagey endorsement.
Answer: The continued repetition of proactive support of labour in italics is meant to emphasise the importance of providing the whole package of care. No single component of this approach can be safely omitted because, like a jigsaw puzzle, the pieces fit snugly together to form a composite picture. Proactive support of labour is, indeed, the panacea to most ills and challenges in maternity care, as the evidence clearly showes. Irritation and reminiscence of “Victorian advertisements” are entirely Montagu’s connotation.
11. Montagu doubts: I do feel the book is worth reading, and I do feel that the authors make some very cogent points in reminding practitioners of the centrality of physiology, the importance of support in labour and the significance of team-work from all those involved in maternity care (although the focus is clearly on US rather than UK organisational structures). However, I still feel that there is an insurmountable paradox in insisting on physiology while maintaining rigid time frames for labour, a 42 week cut-off for the duration of pregnancy and a firm belief in the innocuousness of exogenous oxytocics for augmentation.
Answer: Although our critic acknowledges the many sensible and very cogent points we make, she still fails to see that prevention of long labour is a crucial part of integral quality care aimed at a safe, spontaneous, and rewarding delivery. All aspects of high quality care are strongly interdependent. And when asked, no single pregnant woman wants her forthcoming labour to last longer than 12 hours, and we have yet to meet the first woman who complains that her labour was too short.
No single aspect of our approach is based on “belief”. On the contrary, each and every component - including the in- and exclusion criteria for safe and effective use of oxytocin - is strongly supported by solid clinical evidence. Our advice is to re-read the book and now with an open mind without prejudice, placing the interests of labouring women first. Each and every one of us involved in caring for women in childbirth should re-examine and re-define their practices for the future of normal birth not only for now, but for the next generation. The gap between obstetrics and midwifery must be bridged for the sake of all pregnant women, and proactive support of labour is the best way to accomplish this. The ability to offer real support and effective help at the beginning of life is both a challenge and a privilege.