Fear and birth

We went to see the film ‘After Earth’(http://www.afterearth.com/site/) this week. I don’t really want to write about the film which I felt was a bit of proud father Will Smith pushing his son teenage Jayden further into the limelight. However there was one quote in the film that struck a chord with me and I drifted off into the world of birth. The character Will plays says to his son: ‘Every single decision we make will be life or death. But if we are going to survive this, you must realize that fear is not real. It is a product of thoughts you create. Now do not misunderstand me. Danger is very real, but fear is a choice’. I have been pondering this quote ever since. I will unpack this later.

Last week I was at the 8^th normal birth research conference in Lancashire (http://www.uclan.ac.uk/conference_events/normal_labour_birth.php ) and the word ‘fear’ turned up in many of the presentations and discussions. Fear and anxiety of women around birth has suddenly become a buzz word around labour and birth, especially with concerns around increasing technology and surgical intervention. I would argue though that fears around birth and becoming a mother have always been there. In fact in the not so distant past in the UK women had much greater reasons to fear birth than we have now, with maternal and infant mortality and morbidity rates being high. Birth was placed firmly in the community, an accepted part of life. Midwives were part of that community and part of the families. Women were perhaps more resilient and accepting than today and knew that the processes of life (and death) could not always be controlled.

The 9^th edition of Mayes’ midwifery from 1979 (yes-my original text book for my training!) has a chapter on psychology of pregnancy which is 4 pages long; one page includes the psychological needs of the husband [sic] and those of the other children. But fear for the woman is there too:

‘Anxieties increase as labour approaches and during the last weeks fears for her own well being and that of the baby increase. This is not unreasonable , as every woman must be aware there is a risk of death in childbirth, however much the conditions may have improved. She will aslo be aware that babies are stillborn and are born with abnormalities. These fears are often magnified by misguided friends and old wives tales. Everyone likes to recount the drama of their own pregnancy and labour, and so few the joys and pleasures they experienced.’(P131)

The instructions to us as midwives in those days were to recognise this and to build up confidence so that she will ‘reveal her anxieties and give one the opportunity to help her’. Spending time in clinics and listening are key recommendation. And guess what, this is what is missing in much of the hurried antenatal appointments women have at the moment: lack of relationship and lack of time.

I also have considered this issue of fear from my personal experience of pregnancy and birth. I recognise I am a bit privileged to be able to say that I had five births at home with the care of experienced midwives (the first wasn’t meant to be at home-she came a bit quicker than expected!), and I intend to analyse these stories one day. But I look back and think ‘was I scared?’- yes, a bit, and my husband was a bit, and wondered how I could love 2 (3,4,5) as much as I loved the first (and yes I do)- but was I  ‘fearful’- no, I wasn’t. I agree I had been a midwife and had seen home birth and realised it was the best option, but I also trusted the midwives I was with and I trusted my body was going to work. I was also conscious of being willing to ‘go with the flow’ whatever that meant and not hold back. We just got on with the daily aspects of life while labour was progressing, until it was time to get on with it- a bit different perhaps to the panic of ringing the hospital at the first contraction and rushing in straight away that is portrayed in some many soaps, comedy programmes or films and appears to be the norm for many women today.

So why are women doing this? I certainly think it is about midwives being ‘absent’ to women, not building up relationships and not being there on the end of a phone very often. The way services are constructed means that women don’t know who to call and don’t have the midwife coming round to their home to see what is happening before they go into hospital. To any woman ‘labour is labour’ (Dixon et al 2013 http://www.sciencedirect.com/science/article/pii/S0266613812001246 ) and they would like to know someone is there for them when they are scared and alone. It’s no wonder that those who can afford a doula will do so.

Between my first and last births there was a change in midwifery care in that the concept of ‘risk management’ had appeared. I can remember for the last the ’36 week talk’ by the midwives in my home which took an hour of them telling me the ‘risks’ of me choosing to have a home birth (please remember this was my 5^th-but they still ‘covered their backs’). The concept of ‘risk’ means that women are being overloaded with facts (which are often presented in a negative way) and this introduces another level of fear. Such a difference to the attitude of: ‘home birth? Great. I believe you can give birth and I will support you.’  I think that fear has always been there but it’s the person being alongside and the systems have changed.

In a Swedish study it has been shown that attitudes of women and levels of fear does appear to have an impact on the type of birth she will have. A positive attitude and lack of fear is more likely to enable a straightforward birth (Haines et al 2012 http://www.biomedcentral.com/1471-2393/12/55 If this is the case, and we really do want to reduce intervention rates world wide then we need to take fear of birth seriously.

Back to Will Smith-I actually don’t agree with the quote as I consider fear does exist and we should not ignore it. As midwives we should not be pathologising fear but acknowledging, as my text book did in 1979, that this may be a normal development for women that should be addressed. To this end I suggest the following:

1. Recognise the individual needs of women and that fear can have an impact on birth
2. Don’t ignore fear. If women are fearful we should provide opportunity for them to raise these fears, to take time to listen and find ways to support and reduce the anxiety.
3. Fear is a choice to a level and midwives can also choose to believe in the positive, which it is more likely for birth to go right than to go wrong, and to stop looking for the negatives.
4. Organise services better so that women have the opportunity to have time with midwives to have a relationship that is supportive in the antenatal period so that they feel able to raise their fears.
5. Ensure women and their partners know who to call when they start labour so that they gain support to help them and don’t go into hospital too soon- but also that they are not left scared at home. Can midwives find a way to give home visits in labour to be alongside women so that they can stay at home longer and reduce intervention in busy hospitals?

Nothing I have said above is new- this has been talked about since I started midwifery in the 1980’s. However as fear is being discussed more as an aspect of women’s need and as a potential ‘cause’ for intervention the issues of midwifery care need revisiting. Good midwifery support and care works and getting it right will lead to cost saving in the end.