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Understanding Anxiety, Worry and Fear in Childbearing A Resource For Midwives and Clinicians Dropbox Download

The book 'Understanding Anxiety, Worry and Fear in Childbearing' addresses the impact of fear on women during pregnancy and childbirth, emphasizing the need for supportive relationships in maternity care. It explores the causes of fear, including past trauma and the medicalization of childbirth, while advocating for continuity of care and listening to women's experiences. The resource aims to educate midwives, clinicians, and expectant mothers about the complexities of anxiety and fear in childbearing, fostering a dialogue around these often-hidden issues.
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100% found this document useful (14 votes)
285 views16 pages

Understanding Anxiety, Worry and Fear in Childbearing A Resource For Midwives and Clinicians Dropbox Download

The book 'Understanding Anxiety, Worry and Fear in Childbearing' addresses the impact of fear on women during pregnancy and childbirth, emphasizing the need for supportive relationships in maternity care. It explores the causes of fear, including past trauma and the medicalization of childbirth, while advocating for continuity of care and listening to women's experiences. The resource aims to educate midwives, clinicians, and expectant mothers about the complexities of anxiety and fear in childbearing, fostering a dialogue around these often-hidden issues.
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© © All Rights Reserved
We take content rights seriously. If you suspect this is your content, claim it here.
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Understanding Anxiety, Worry and Fear in Childbearing A

Resource for Midwives and Clinicians

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Editor
Kathryn Gutteridge
NHS Trust City Hospital
Sandwell & West Birmingham Hospital
Birmingham
UK

ISBN 978-3-030-21062-5    ISBN 978-3-030-21063-2 (eBook)


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Foreword

Fear is corrosive, relentless and contagious. It limits our potential and prevents us
from doing our best as mothers, midwives and obstetricians. Fear can cast a dark
shadow over pregnancy and birth and inhibit optimal hormonal function. At a time
when birth has never been safer, it is sadly ironic that we are only just becoming
aware of the tragic impact of fear upon mothers and all those involved in birth. Fear
around birth is increasing, and this book makes an important contribution to our
knowledge in this neglected area. It contains some outstanding chapters.
Birth takes place within a culture, and our culture is focussed on economic
growth that requires ever developing technologies, products and markets and pro-
motes growth by advertising which is often fear inducing. Birth is about relation-
ships and trusting relationships can resolve fear, but the organisation of maternity
services on an industrial model does not allow relationships to flourish. In some
cases, institutional safety procedures play a considerable part in creating and sus-
taining fear.
Different chapters bring out the long-term impact on women of not being
believed, whether as abused children or women in early labour, and the bodily mem-
ories which can be reawakened by “care” during pregnancy and birth. So much fear
has its roots in women’s past experiences of loss of control and the abuse of power
when they were at their most vulnerable. Sadly, for many this abuse was by profes-
sionals in their previous experiences of maternity services.
Positive birth can be healing, and an argument for continuity of midwifery care
runs through this book. Where a trusted midwife can hold safe space for a mother,
it is possible for her to feel sufficient confidence in her carers and her body to let go
and give birth and then hold safe space for her baby. This is an empowering experi-
ence, which is not achieved where women feel they are being processed on a con-
veyor belt and midwives are micro-managed. Chapter authors from very different
backgrounds make strong arguments for listening to women and trusting them and
show how this can transform women’s birthing experience. This is vitally important,
but difficult for midwives who feel that their own voices are not heard and they are
not trusted by management.
The authors explore the complexity of the causes and experiences of fear. There
are no easy answers, no edict, medicalised answer or product, which will solve the
problems created by the abuse of power, medicalisation and the market economy.

v
vi Foreword

There are helpful tips and suggestions for carers to help them protect the woman’s
agency, communicate well and be kind. The importance of listening and trust is a
powerful theme.
This timely book addresses worry and anxiety around birth as well as differing
levels of fear. It brings together recent research, innovations in service provision and
compassionate insights from different fields of work around birth. In a number of
chapters, the issues raised are illustrated with relevant and illuminating stories, a
traditional and memorable way of teaching about birth. So much is conveyed where
the words of suffering women are quoted. There is much here of relevance to moth-
ers, partners, midwives, obstetricians, managers and those who plan and fund
maternity services. This is a book well worth reading.

Mavis Kirkham
Professor Emerita
Sheffield Hallam University
Sheffield, UK
Preface

This book has been on my mind for many years. The women I have encountered
throughout my clinical career both as a midwife and then as a psychotherapist
remind me of the vast amount of work to do in recognising the phenomenon of
fearfulness in our childbearing populations. How does a clinician differentiate
between a worried or anxious woman compared to one who is secretly terrified of a
pregnancy before it has even begun? This book does not claim to answer all the
questions but it does start the narrative and brings the subject matter from within the
hidden corners of women’s lives.
When you begin to read this book, you will note that the authors are in the main
midwives, but there are contributions from an obstetrician, psychiatrist and also a
doula. Whatever the difference in roles, the central experiences of these authors are
that they have encountered, witnessed, and understood the issues they have written
so carefully about. This collaboration is important because women present in many
ways and to various people in their quest to be understood. The style of writing is
largely academic but has a sense of being rooted in the experiences of women. In
every chapter there are references to women’s experiences and in others there are
vignettes or case studies that will elucidate the many ways that women suffer with
their anxieties and fears. Some of the chapters are written with very personal obser-
vations and in the first person that reaches out to those of us who wish to hear the
story.
In deciding how to use the book it may be that student midwives will wish to
understand the nature of the problems and dip in and out of chapters. For women
who are searching for answers to their anxieties this may suit some of those readers,
particularly when looking for answers to approaching future pregnancies and birth.
For maternity clinicians and doulas, this book will provide a comprehensive
analysis of anxiety, fear and in some rare cases tokophobia or morbid fear. The
authors have approached their chapters with an enlightened approach giving insight
into the problems and scenarios that women find themselves facing during their
pregnancies and births. There may be some cross over from chapter to chapter but I
make no apologies for this as it is important in terms of education and encouraging
a deeper understanding.
The chapters themselves give a cultural overview that appreciates the universal-
ity of birth today in our diverse and multicultural societies. Although many of the
authors are working in the United Kingdom, there is a determination to represent

vii
viii Preface

birth from other healthcare systems such as Ireland and Australia. Of course, this is
a small comparison but what the authors show is that this phenomenon is not culture
exclusive and may be found in a wide cultural variance.
Fear as an extreme human experience is a rare event in general adult life.
However, where it is associated with a normal human experience such as child-
bearing then it takes on a more secretive or shameful persona. This is likely to
become a taboo subject and one which is hidden in everyday life. Add into this
another deeply buried secret such as sexual abuse—then the woman is less likely
to disclose her fears. It was important in this book to cover this subject matter as
these women were found to be highly represented in a seminal paper investigating
tokophobia. Maternity clinicians are unlikely to make this association and if they
do, they are often unaware of how to offer care in a sensitive way that reduces
retraumatisation.
Education for psychological well-being, trauma presentations and acute panic/
fear within maternity settings are not mandated. Clinicians will often choose to
attend training or education events such as these because they are interested rather
than their service or professional organisation requires it. A book that covers this
subject matter and is available to a wide clinical and non-professional audience will
serve to educate and inform.
The intention in writing this book is not to give every answer to all of the prob-
lems or to provide a best clinical pathway to offer care to childbearing women. It is
a start to the dialogue; it gives the subject matter importance and thus allows women
to apply a name to their emotions and feelings that may be worrying them. In pro-
ducing a book that begins to give credibility to previously hidden or dismissed anxi-
eties is a leap of faith that cannot be underestimated.
I hope that this narrative is work that will gain strength and inform those provid-
ing care for childbearing women. I also hope that it serves to do justice to the many
women who have suffered their fears in silence and isolation. This is a book that I
wished I could have read many years ago before embarking on the unknown.
In memory of my daughter Rebecca Marie Mistry; she taught me so much watch-
ing her as a mother to both of her sons and I am indebted to her for her intelligent
and mature observations of our healthcare systems. She was the mother I wished I
could have been.

Birmingham, UK Kathryn Gutteridge


Contents

1 History of Fear and Childbearing������������������������������������������������������������   1


Maeve O’Connell and Rhona O’Connell
1.1 Early Modern Period��������������������������������������������������������������������������   2
1.2 Twentieth Century and a New Era������������������������������������������������������   4
1.3 Biomedical Model of Care������������������������������������������������������������������   5
1.4 The Choice for Caesarean Birth����������������������������������������������������������   6
1.5 Respect and Human Rights in Childbirth ������������������������������������������   6
1.6 Tokophobia������������������������������������������������������������������������������������������   7
1.7 Drivers for Change������������������������������������������������������������������������������   9
1.8 Fear of Childbirth and the Risk Discourse������������������������������������������ 10
1.9 Conclusion������������������������������������������������������������������������������������������ 13
References���������������������������������������������������������������������������������������������������� 14
2 Global Perspectives of Childbirth Fear Including the
Relevant Evidence�������������������������������������������������������������������������������������� 19
Helen Haines
References���������������������������������������������������������������������������������������������������� 25
3 Understanding Fear, Physiology and Finding an Explanation
of How the Mind Influences Us During Childbearing���������������������������� 31
Kathryn Gutteridge
3.1 Defining Anxiety and Worry �������������������������������������������������������������� 32
3.2 The Brain�������������������������������������������������������������������������������������������� 32
3.3 Memory���������������������������������������������������������������������������������������������� 36
3.4 How Do We Know Who Will Be at Risk of a Traumatic Events�������� 38
3.5 Pregnancy: An Emotional State���������������������������������������������������������� 39
3.6 Dreams and Fantasies ������������������������������������������������������������������������ 41
3.7 During Sleep �������������������������������������������������������������������������������������� 41
3.8 Neurochemistry of the Brain and Hormones�������������������������������������� 42
3.9 The Nature of Fear������������������������������������������������������������������������������ 44
3.10 How Do We Deal with This?�������������������������������������������������������������� 44
3.11 Phobia and Avoidance Behaviour ������������������������������������������������������ 45
3.12 Unremitting Fear�������������������������������������������������������������������������������� 47
3.13 The Formation of Terror��������������������������������������������������������������������� 47

ix
x Contents

3.14 The Concept of Body Awareness�������������������������������������������������������� 49


3.15 Final Thoughts������������������������������������������������������������������������������������ 50
References���������������������������������������������������������������������������������������������������� 50
4 Fear of Birth and Modern Maternity Systems of Care�������������������������� 53
Geraldine Butcher and Clare Willocks
4.1 Introduction���������������������������������������������������������������������������������������� 53
4.2 Fear of Birth���������������������������������������������������������������������������������������� 54
4.3 Primary Fear���������������������������������������������������������������������������������������� 55
4.4 Secondary Fear������������������������������������������������������������������������������������ 57
4.5 Request for a Planned Caesarean Section������������������������������������������ 59
4.6 Maternity Services and Fear Disclosure �������������������������������������������� 59
4.7 Fear Disclosure and Health Professional’s Attitudes�������������������������� 60
4.8 Challenges to Individualised Care������������������������������������������������������ 61
4.9 Best Intentions Can Lead to Disaster…���������������������������������������������� 63
4.10 … But When We Do Well We Are Brilliant!�������������������������������������� 63
4.11 Place of Birth�������������������������������������������������������������������������������������� 64
4.12 Dealing with Strangers and Vulnerability ������������������������������������������ 66
4.13 Poor Care�������������������������������������������������������������������������������������������� 67
4.14 Survivors of Sexual Abuse������������������������������������������������������������������ 68
4.15 Interventions Which May Help Reduce Fear of Birth������������������������ 69
4.16 Birth Preferences�������������������������������������������������������������������������������� 71
4.17 Conclusion������������������������������������������������������������������������������������������ 72
References���������������������������������������������������������������������������������������������������� 72
5 Gathering Storm–Birth in the Media������������������������������������������������������ 75
Tracey Cooper and Laura Godfrey-Isaacs
5.1 Introduction���������������������������������������������������������������������������������������� 75
5.2 How Pervasive Is the Media?�������������������������������������������������������������� 76
5.3 Definition of, and Theories of, ‘The Media’�������������������������������������� 77
5.4 Dominant Media Messages About Birth�������������������������������������������� 77
5.5 Analysis of Media Images of Birth���������������������������������������������������� 78
5.6 Birth Is Not Porn�������������������������������������������������������������������������������� 81
5.7 Evidence���������������������������������������������������������������������������������������������� 83
5.8 The Safety Agenda������������������������������������������������������������������������������ 83
5.9 Research Studies About the Influence of Media on Women�������������� 84
5.10 A Social Model of Birth���������������������������������������������������������������������� 85
5.11 The Midwifery Model������������������������������������������������������������������������ 87
5.12 A Challenge to Mainstream Media? �������������������������������������������������� 88
5.13 How to Respond to Media Depictions of Birth���������������������������������� 89
5.14 Moving Forward with Positive Media Messages�������������������������������� 89
5.15 Final Word������������������������������������������������������������������������������������������ 91
References���������������������������������������������������������������������������������������������������� 92
Contents xi

6 Childhood Sexual Abuse, Sexual Assault, Rape and Its


Relevance to Childbearing Fear �������������������������������������������������������������� 97
Kathryn Gutteridge
6.1 Developing into ‘Me’�������������������������������������������������������������������������� 98
6.2 Adverse Life Events���������������������������������������������������������������������������� 98
6.3 Childhood Sexual Abuse and Childhood Sexual Exploitation������������ 100
6.4 Impact of CSE on Cognitive Development���������������������������������������� 102
6.5 How Many Women ���������������������������������������������������������������������������� 103
6.6 To Tell or Not to Tell�������������������������������������������������������������������������� 104
6.7 What Has This to Do with Maternity?������������������������������������������������ 105
6.8 Stranger in the Birth Room ���������������������������������������������������������������� 109
6.9 What Is to Be Done? �������������������������������������������������������������������������� 112
6.10 Disclosure of Sexual Abuse���������������������������������������������������������������� 112
6.11 Advice for Disclosures������������������������������������������������������������������������ 112
6.12 Antenatal Risks ���������������������������������������������������������������������������������� 113
6.13 Advice During Antenatal Care������������������������������������������������������������ 114
6.14 Labour Risks �������������������������������������������������������������������������������������� 114
6.15 Advice During Labour������������������������������������������������������������������������ 114
6.16 Postnatal Risks������������������������������������������������������������������������������������ 115
6.17 Advice for Postnatal Period���������������������������������������������������������������� 116
6.18 Finally ������������������������������������������������������������������������������������������������ 116
References���������������������������������������������������������������������������������������������������� 116
7 ‘Who’s Afraid of the Big Bad Birth’: Childbirth Trauma,
Fear and Tokophobia �������������������������������������������������������������������������������� 121
Kathryn Gutteridge and Yana Richens
7.1 Introduction���������������������������������������������������������������������������������������� 121
7.2 Into the Deep�������������������������������������������������������������������������������������� 122
7.3 The Pregnancy Confirmed and Fear Is Realised�������������������������������� 125
7.4 Primary Tokophobia���������������������������������������������������������������������������� 126
7.5 Vignette 1�������������������������������������������������������������������������������������������� 127
7.6 Vignette 2�������������������������������������������������������������������������������������������� 128
7.7 Vignette 3�������������������������������������������������������������������������������������������� 131
7.8 Vignette 4�������������������������������������������������������������������������������������������� 133
7.9 Trauma: ‘An Extraordinary Event That Happens to
an Ordinary Person’���������������������������������������������������������������������������� 135
7.10 The Manifestation of Birth Trauma���������������������������������������������������� 135
7.11 Risk Factors for PTSD in Childbirth�������������������������������������������������� 138
7.12 Vignette 5�������������������������������������������������������������������������������������������� 139
7.13 Fear Associated with Body Image and Function�������������������������������� 140
7.14 Vignette 6�������������������������������������������������������������������������������������������� 140
7.15 Challenges: Request for Caesarean Section���������������������������������������� 142
7.16 Vignette 7�������������������������������������������������������������������������������������������� 142
7.17 Finally ������������������������������������������������������������������������������������������������ 143
References���������������������������������������������������������������������������������������������������� 143
xii Contents

8 Working with Worry and Inspiring Hope: Relationships


with Anxious and Fearful Women������������������������������������������������������������ 147
Hannah Dahlen, Alison Teate, Simone Ormsby,
and Virginia Schmied
8.1 What Is Anxiety and Worry?�������������������������������������������������������������� 148
8.2 Which Women Are More Likely to Experience Worry or Anxiety?�� 149
8.3 The Impact of ‘Good Mother’ Discourses������������������������������������������ 150
8.4 Our Health Systems Are Manufacturing Worry���������������������������������� 152
8.5 Asking Women About Worry Is Exposing the Worry ������������������������ 152
8.6 Dealing with Uncertainty�������������������������������������������������������������������� 153
8.7 How Coercion Can Result from Marketing of Fear���������������������������� 153
8.8 How Do Relationships Impact on Worry/Anxiety������������������������������ 154
8.9 Working with Worry in the Antenatal Period�������������������������������������� 157
8.10 Creating a Sense of Hope�������������������������������������������������������������������� 158
8.11 How Midwives Use Time to Work with Worry���������������������������������� 159
8.12 How Can Complementary Therapies Help Moderate Worry?������������ 160
8.13 How Can We Work Positively with Worry/Anxiety?�������������������������� 161
8.14 Working with Fear and Not Against It������������������������������������������������ 163
8.15 Conclusion������������������������������������������������������������������������������������������ 163
References���������������������������������������������������������������������������������������������������� 164
9 ‘Getting it Right First Time’: The Effects of Anxiety
and Fear on a Birthing Woman���������������������������������������������������������������� 171
Helen Shallow
9.1 Freya’s Story: A Case Study �������������������������������������������������������������� 171
9.2 Background ���������������������������������������������������������������������������������������� 171
9.3 Discussion ������������������������������������������������������������������������������������������ 183
9.4 Conclusion������������������������������������������������������������������������������������������ 185
References���������������������������������������������������������������������������������������������������� 187
10 Maternity Policy and a Generation of Anxiety and Fear ���������������������� 189
Julia Lidderdale and Kathryn Gutteridge
10.1 Introduction�������������������������������������������������������������������������������������� 189
10.2 In the Beginning: Julia���������������������������������������������������������������������� 190
10.3 In the Beginning: Kathryn���������������������������������������������������������������� 191
10.4 The Impact of the Peel Report���������������������������������������������������������� 197
10.5 The Evidence Breaks Through���������������������������������������������������������� 198
10.6 The Winterton Report ���������������������������������������������������������������������� 198
10.7 Changing Childbirth: Choice, Control and Continuity �������������������� 199
10.8 Caesarean Section in Ascendency���������������������������������������������������� 200
10.9 But in the Background���������������������������������������������������������������������� 200
10.10 And Yet More Evidence�������������������������������������������������������������������� 202
10.11 Morecambe Bay: Kirkup 2015���������������������������������������������������������� 203
10.12 Better Births 2016 ���������������������������������������������������������������������������� 203
10.13 Women’s Choice and Policy Today�������������������������������������������������� 204
10.14 Women: Being Informed������������������������������������������������������������������ 204
10.15 Conclusion���������������������������������������������������������������������������������������� 206
References���������������������������������������������������������������������������������������������������� 207
Contents xiii

11 Never Safer; Never More Afraid: Women’s Voices


and Stories of Childbearing and Fear������������������������������������������������������ 211
Cathy Williams
11.1 Pre-existing Anxiety�������������������������������������������������������������������������� 213
11.2 Sexual Assault Survivors������������������������������������������������������������������ 215
11.3 Fear and Anxiety About Labour and Birth���������������������������������������� 215
11.4 Fear of Baby Dying�������������������������������������������������������������������������� 216
11.5 Pre-existing Fears About Birth���������������������������������������������������������� 217
11.6 Choosing an Elective Caesarean ������������������������������������������������������ 218
11.7 Previous Difficult Birth�������������������������������������������������������������������� 218
11.8 Other Individual Situations �������������������������������������������������������������� 220
11.9 Going into Labour���������������������������������������������������������������������������� 220
11.10 Pain of Labour���������������������������������������������������������������������������������� 221
11.11 Other Fears���������������������������������������������������������������������������������������� 222
11.12 Experiences of Maternity Care/Antenatal Care�������������������������������� 223
11.13 Experiences of Screening������������������������������������������������������������������ 225
11.14 Antenatal Classes������������������������������������������������������������������������������ 227
11.15 Late Pregnancy���������������������������������������������������������������������������������� 228
11.16 Labour ���������������������������������������������������������������������������������������������� 229
11.17 Postnatal Ward���������������������������������������������������������������������������������� 231
11.18 Partners �������������������������������������������������������������������������������������������� 232
11.19 Meera’s Story������������������������������������������������������������������������������������ 232
11.20 What Would the Future Look Like?�������������������������������������������������� 233
11.21 Continuity of Carer �������������������������������������������������������������������������� 233
11.22 Support for Mental Health���������������������������������������������������������������� 233
11.23 Individualised Care �������������������������������������������������������������������������� 234
11.24 Language������������������������������������������������������������������������������������������ 234
11.25 Working with Women Who Have Fear and Anxiety������������������������ 236
11.26 Conclusion���������������������������������������������������������������������������������������� 236
References���������������������������������������������������������������������������������������������������� 237
12 Shifting Tides—from Storm to Salvation������������������������������������������������ 239
Sheena Byrom and Anna Byrom
12.1 Shared Stories ���������������������������������������������������������������������������������� 239
12.2 Background �������������������������������������������������������������������������������������� 240
12.3 Country-Level Change���������������������������������������������������������������������� 241
12.4 Service-Level Shifts�������������������������������������������������������������������������� 245
12.5 Individual Maternity Worker������������������������������������������������������������ 248
12.6 Top Tips to Support Change������������������������������������������������������������� 251
References���������������������������������������������������������������������������������������������������� 252
History of Fear and Childbearing
1
Maeve O’Connell and Rhona O’Connell

The greatest battle that ever was fought—Shall I tell you where and when?On the maps of
the world you will find it not:It was fought by the Mothers of Men. (Joaquin Miller
[1837–1913])

Childbirth has undergone considerable change over the past few centuries. Outcomes
have improved due largely to improvements in the health and well-being of women
and babies, but also to the increase in knowledge about pregnancy and childbirth.
Unfortunately, standards of maternity care are variable; there are concerns about
levels of intervention in childbirth in many parts of the world, while there is a lack
of resources to ensure safe childbirth in many low resource countries (Miller et al.
2016). Sadly, mainly in low to middle income countries, there is widespread neglect
and abuse of childbearing women by health care professionals (Bowser and Hill
2010). Women report a positive childbirth experience when they are treated with
respect and feel safe. Unfortunately, many women also experience fear of childbirth
and this is not always recognised (O’Connell et al. 2019). In this chapter, firstly we
will explore birth and how it is documented through the ages, with relevance to the
historical culture of birth and birth workers. Secondly, we will discuss what has
influenced changes in maternity care provision and shaped women’s thinking about
birth and its consequences for today’s women.

M. O’Connell
School of Nursing and Midwifery, Royal College of Surgeons Ireland in Bahrain,
Muharraq, Bahrain
The Irish Centre for Fetal and Neonatal Translational Research (INFANT Centre),
University College Cork, Cork, Ireland
e-mail: [email protected]
R. O’Connell (*)
The Irish Centre for Fetal and Neonatal Translational Research (INFANT Centre),
University College Cork, Cork, Ireland
e-mail: [email protected]

© Springer Nature Switzerland AG 2020 1


K. Gutteridge (ed.), Understanding Anxiety, Worry and Fear in Childbearing,
https://doi.org/10.1007/978-3-030-21063-2_1
2 M. O’Connell and R. O’Connell

1.1 Early Modern Period

Since the first recorded births, midwives have accompanied and assisted women
through pregnancy and childbirth. It is likely that married women came to fulfil this
role as required, and, once they assumed it, they gained experience and became known
as the ‘midwife’ or ‘handywoman’. It has been suggested that in the early modern
period there was considerable variation in the practices, skills and competence of
midwives, with some practicing occasionally as the need arose, while others made
their living from this role (Marland 1993). Apart from myths and folklore, childbirth
itself was largely undocumented but it is likely that knowledge and practices of mid-
wives was passed by word of mouth with skills acquired by observation and experi-
ence. Unfortunately, the oral traditions of midwives are largely unrecorded.
Childbirth came under scrutiny by the Catholic Church following the Council of
Trent in 1545. The concept of original sin became central to Christian faith and thus
the Church became interested in the practices of midwives. To ensure salvation, it
was considered vital that any infant thought likely to die should be baptised as soon
as possible, and thus it became a midwife’s duty to baptise the child if required,
even if this necessitated the removal of the infant by caesarean section in the event
of the woman’s death (Donnison 1988). Licences were granted to midwives who
could present evidence of their skills and religious orthodoxy. To obtain her licence,
the midwife was required to swear not to use ‘any sorcery, divination or magick,
incantations, witchcraft or any superstitious, hellish or horrid methods’ (Devane and
Murphy Lawless 2005). By the sixteenth century in Europe, some physicians had
taken an interest in childbirth and began to organise and regulate midwives’ prac-
tice. The municipal authorities took over the licensing of midwives from the church;
these fortunately paid more attention to the technical competence of the midwives
rather than their moral character. Childbirth was women’s business and women
relied on other women for information and support. For the most part, midwives
were probably skilled in straightforward births, and would have had to deal with
difficulties in childbirth themselves, as physicians were concerned neither with the-
ory nor the practice of midwifery until the seventeenth and eighteenth centuries. Not
surprisingly, these midwives generally lacked knowledge, given that few women
had access to education of any kind. While the midwife was a respected member of
the community, both maternal and perinatal mortality rates were high.
Although there was no safe treatment for obstructed labour, puerperal fever,
haemorrhage or eclampsia, maternal death rates declined over time probably due to
improvements in general health and living conditions (Peller 1943). From the sev-
enteenth century on, midwifery practices were mainly recorded by the male domi-
nated medical profession. Early midwifery textbooks were written by doctors based
on the practices learnt from midwives. The midwife was a respected member of the
community and though, later she was often castigated by medical doctors, there is
no evidence that midwifery practices throughout the ages were harmful, in fact,
early lying-in hospitals had high levels of maternal deaths as sepsis was more likely.
Through the eighteenth and nineteenth century, more hospital beds were provided
for childbearing but women were reluctant to attend a hospital for birth and would
prefer to call a midwife of her choice to assist with a home birth.
1 History of Fear and Childbearing 3

Over time, medical men become the dominant voice for safety in childbirth and
it was easy for them to single out poor midwifery practice. Despite this, although
the destitute poor were cared for by uneducated midwives, it was reported that their
maternal death rate was considerably less than women who gave birth in lying-in
hospitals attended by men (Donnison 1988). For midwives, while their knowledge
may have increased over time, access to education was limited; women had little
economic or legal protection and were limited in their work opportunities (Wiesner
1994). However, in many areas women would have a choice of which midwife to
call for their birth and the reputation of the midwife was important for her to remain
in employment.
A danger for childbearing women was infection or child-bed fever. In hospitals,
the risk of puerperal sepsis was particularly high. In Vienna, Ignaz Semmelweis
observed that women delivered by doctors and medical students were more likely to
die from puerperal fever than women delivered by midwives (Citrome 2018). He
noted that doctors were performing autopsies prior to attending the births, whereas
midwives did not. He introduced the practice of hand decontamination with chlo-
ride of lime and the mortality rate of women dropped to that of the level concomi-
tant with midwives (Murphy Lawless 1998). Despite publishing his findings, this
practice did not become accepted until many years after his death. Over time, the
number of maternal deaths reduced due to an increased understanding of ‘germs’ as
a mechanism of childbirth fever.
An important development in the seventeenth century was the obstetric forceps
of the Chamberlain family, prior to this, a crochet hook was commonly used to
extract a dead fetus (Gorey 2012). Over time, various instruments were invented but
the baby rarely survived. The forceps developed by Chamberlain family was suc-
cessful in extracting live babies, but they kept this intervention secret for the next
150 years (O’Dowd and Philipp 2000). By the mid-eighteenth century midwives
realised the need for skilled help from men in certain cases. An understanding
developed between some female midwives and doctors with their instruments so
that if difficulties arose the midwife would call the doctor for assistance. Many
however, both doctors and midwives opposed the growth of the indiscriminate use
of forceps (Aveling 1967).
Caesarean sections were rare and usually performed in an effort to save a baby if
the woman had died. By the nineteenth century, surgical techniques improved and
with developments in anaesthesia and asepsis, over time, caesarean sections became
safer. The term ‘once a caesarean, always a caesarean’ first appeared in 1916 (Todman
2007). For women to remain in bed for several days after the birth was encouraged;
during this lying-in period the physician might visit (Morris Slemons 1912) but the
midwife would attend to provide practical support and assist with household tasks.
Fear of childbirth during pregnancy has been documented as far back as the sev-
enteenth century, when Osiander, a physician in Germany wrote about women who
committed suicide rather than endure childbirth (O’Connell et al. 2015). In France,
Marce similarly documented cases of pregnant women who jumped in the river or
gassed themselves. In 1858; He described where pregnant women ‘…are privately
convinced that they are going to die from the ordeal that awaits them. The idea
becomes fixed in their heads and triggers a melancholy which takes over all her
4 M. O’Connell and R. O’Connell

thoughts’ (O’Connell et al. 2015). Marce compiled a monograph of 79 perinatal


psychiatric cases but his work was paid little attention in his lifetime (Trede et al.
2009). The subspecialty of perinatal psychiatry has only recently emerged and
Marce’s work a ‘Treatise on Insanity in Pregnant, Postpartum, and Lactating
Women, and Related Medicolegal Considerations’ is now recognised as making a
significant contribution to the body of knowledge. In his work, Marce observed that
fear of childbirth and depression were associated and that the perinatal period was a
time in which women were more likely to develop depression, psychosis and acute
mood disorders (Trede et al. 2009). This is now recognised as tokophobia.
Throughout this period, puerperal psychosis was seen as part of the dangers
associated with childbirth such as fever, haemorrhage and the other disorders mid-
wives encountered. Women with mental health problems were often admitted to
asylums. Marland (2003) reviewed asylum records and reported that apart from the
various treatments offered, there seemed to be a greater understanding for poor
women that their insanity, which was described as mania or melancholia, was asso-
ciated with a variety of social and environmental factors. This included the fear and
anxiety associated with illegitimacy, but also exhaustion, malnourishment and the
hardships associated with repeated child-rearing. Recovery was usually achieved,
and women returned to their families.

1.2 Twentieth Century and a New Era

By the twentieth century, there was a gradual and then more rapid move to hospital
birth for all. Where women gave birth at home, they had support from family and
friends and were likely to have assistance from a known midwife or general practi-
tioner. When hospital birth became the norm, this led to more women giving birth
among strangers (Walzer Leavitt 1986). The early development of maternity hospi-
tals was to provide care for the deserving poor, and destitute women were encour-
aged to attend charity hospitals, later as national health services developed and with
advances in options for pain relief for labour, women were encouraged to attend
nursing homes or local hospitals to give birth. This might also give women a wel-
come break from their duties at home. As physicians were advancing their knowl-
edge around birth which became increasingly medicalised and pathologised, the
woman’s birth experience was not important once the woman and baby were healthy
on hospital discharge. The myth that hospital birth was safer became the accepted
dogma (Tew 1995). Practices such as twilight sleep were introduced, where women
experienced the pains of childbirth but by the administration of scopolamine and
morphine at the time of birth, forgot the experience and woke to see their baby in a
fog of anaesthesia (Michaels 2018). Restrictive practices ensured that women could
not make decisions about their care. Symphysiotomies were performed in order to
avoid a caesarean section, later and still today in many countries, episiotomies are
widely performed. In the future, will we think it strange that women experiencing
normal birth were giving birth in lithotomy or supine positions ergo?
1 History of Fear and Childbearing 5

Towards the latter half of the twentieth century, various reports condemned home
birth and most women moved towards obstetric-led services with increasing reli-
ance on technology and intervention for birth. Initially, the risk of death from puer-
peral fever or haemorrhage was a driver for the movement to hospital birth, however
it was later that Tew (1995) identified that improvements in childbirth were not due
to the increased hospitalisation and the provision of medical care; rather, they were
due to improvements in health and social conditions of women and their families.

1.3 Biomedical Model of Care

Throughout the twentieth century, developments in maternity care led to increasing


dominance in obstetric models of care. Green and Baston (2007) noted this change
when they explored women’s expectations and experiences of childbirth in 1987
and again in 2000. They found that women in the later survey were far more willing
to accept obstetric interventions than the women surveyed in 1987.
One of the myths about childbirth is that it is in the best interest of woman and
baby that birth takes place in hospital. This global trend for birth to occur in larger
maternity units is problematic for women who are at low risk of complications, as
large units have a greater propensity for intervention in labour, and lower rates of
spontaneous births (O’Connell et al. 2003).
Davis-Floyd (1994) introduced the term technocratic birth to the debate on child-
birth when she observed that the changes in maternity care occurred in parallel with
an increasing reliance on technology throughout society. In this interpretation both
doctors and midwives accept high levels of intervention and readily adopt prevailing
technology in the belief that it leads to best outcomes for women and their babies
(Davis-Floyd 1994). The term technocratic birth takes the emphasis from the medi-
cal profession as being solely responsible for the levels of surveillance and interven-
tion in childbirth, acknowledging that doctors, midwives and women are also caught
in this technocratic age.
The term medicalisation of childbirth implies that the power in this model of care
lies with the medical profession; however, in many countries, midwives undertake
much of the care of women throughout labour and birth. It appears that midwives
have adopted many of the advances in technology without much debate. Sinclair
and Gardner (2001) reported that midwives reject the possibility of being over
dependent on technology and Kennedy (2002) found that even midwives who sup-
port normal birth may adopt technology in order to optimise birth outcomes and
possibly reduce the need for further interventions.
Current debates in maternity care include the increasing use of technology and
intervention in childbirth. Concerns have been raised in many disciplines, from
medicine and midwifery, to sociology, anthropology and others about the impact
that this has on women’s experience of birth. Different issues prevail in community
settings, but, in the developed world most births occur in hospital where technology
and intervention have become normalised.

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