The Forceps and The Damage Done

The recently published—and brilliantly written—Jo Murphy-Lawless's Reading Birth and Death: A History of Obstetric Thinking provides an incisive and sometimes shocking insight into obstetric practice in Ireland.

Murphy-Lawless's book comes at a significant time in the history of Irish obstetrics. Recently, several cases of serious malpractice—including that of a Drogheda obstetrician who has been performing apparently unnecessary hysterectomies on women for the past few years—have come to light, pointing to "grave problems within the whole system of birth," according to Murphy-Lawless.

"For me, it's an issue of obstetric power," says the author, a fast-talking woman who exudes a profound sense of experience and professionalism. "I wrote this book because I felt we needed an explanation in the Irish context of why it was that women over the past 25 years remain very disturbed by their childbirth experiences in hospitals."

Given the strong culture of patriarchal control over reproduction in Ireland, it's not surprising to hear that the Irish obstetric situation is particularly disturbing.

"There's been an intensification of obstetric power over a period of about 250 years now," she says. "The obstetric impulse has always been to cut, to get open, to use forceps to pull out and so on. What is interesting is how early on in the 19th century the forceps was normalised as a strategy, rather than being something to be used in an emergency situation when a baby was seriously obstructed. Many obstetricians argued that it should become the norm in terms of delivery practices.

"There was an obstetrician in the Edinburgh University in the 1820s to the 1840s, James Hamilton, who argued that it was very important to shorten the amount of time that a woman was in labour, and the forceps was very useful in this respect. This kind of thinking was picked up by George Johnston, an obstetrician in Dublin's Rotunda Hospital, in the 1860 to 1875 period. He said the shorter the labour, the less likely it was that a woman would suffer from puerperal fever [post-birth infection]. And, in particular, he said that women who were unmarried were particularly susceptible to puerperal fever, and it was particularly important to use the forceps on those women at a very early stage."

According to Murphy-Lawless, invasive birth technologies which have now become the norm—such as forceps delivery—are based on a belief in women's incompetence, and a disrespect for women's knowledge of their own bodies.

"There are alternatives which exist elsewhere that haven't even begun to see the light of day here. And to me that suggests an extreme inflexibility on the part of the obstetric establishment. Certainly the experiences of women at a personal level suggest to me that we do have a particular problem here in Ireland, with treatment which women find either distressing or degrading, and, in some cases extremely traumatic. And it is not acceptable."

Today, if an Irish woman wants a natural birth, she faces an uphill struggle, and gets subjected to a great deal of medical "shroud-waving", which Murphy-Lawless defines as the threat that if you refuse current hospital birth practices, you are risking your baby's life. How do the mortality rates between hospital and home or natural births compare?

"The only sets of extensive statistics over a long period of time are figures from the Netherlands," says Murphy-Lawless, "which indicate that when birth is left in the hands of midwifery management, the perinatal mortality rates are in fact far better than they are once you get into a hospital setting. The obstetricians contest these figures and say they get all the complicated cases, but I think there's a strong body of research now which has confronted obstetricians on this and said that basically, once you get involved as obstetricians, you are interfering in a process, and you create complications. You interrupt a process with your technologies, with your interventions, and then it can indeed go to a crisis situation, where we're going to need more interventions, which you've created by intervening in the first place."

Murphy-Lawless refers to this phenomenon as the "cascade of intervention".

"The problem is," she comments, "that once you take this very intricate physiological, psychological package of labour and birth, once you interrupt that process with the many interventions which obstetrics has, then you're going to have to interrupt all the way along the line."

But surely modern obstetrics is responsible for the massive drop in birth mortality rates that has occurred in the past centuries?

"There are a wider number of factors than obstetric claims to have brought down both maternal and infant mortality," observes Murphy-Lawless. "And the most striking factors are socio-economic. Once you have much better general health profiles for women, once you have women being able to control their fertility safely so they're not getting pregnant ten or 15 times in the course of their reproductive years, once you have much better hygiene in hospital spaces, once you have antibiotics and can control infection, then you're going to be able to bring down both infant mortality and maternal mortality. So there's a whole bundle of factors."

Of the average 50,000 births that take place in Ireland every year, only about 200 are home or natural births. There are only 20 home-birth midwives practising in Ireland, and they cannot even begin to meet the demand. Engaging the help of an independent midwife is the only way a woman can guarantee that she will not be subjected to invasive birth techniques. Yet Ireland's independent midwives are seriously marginalised by the obstetric establishment. The current case of midwife Ann Kelly—a home-birth midwife who was suspended from practising her profession on the word of an obstetrician and a hospital matron—seems to put the tiny Irish home-birth movement on trial. Murphy-Lawless places this development in its historical context.

"What obstetric medicine consistently said once it came into being in the 18th century was, 'We have a more perfect understanding, because ours is a scientific understanding compared with midwives. Therefore midwives must be subordinate to our understanding, and if they are to practise at all, we must train them in our structures and our way, to handle the body the way we want it handled.'"

According to Murphy-Lawless, far greater transparency on the part of the obstetric establishment is a vital factor in finding solutions to the current crisis of birth management in Ireland.

"The establishment has to open its doors to dialogue and to negotiation with all the stakeholders," she asserts. "At present it almost sounds as if the principal stakeholder and the only stakeholder is the obstetric establishment itself. It is not the only stakeholder. The women who are bearing children, the women contemplating pregnancy, the children themselves and midwives—we are the principal stakeholders. But we're actually cut out from dialogue at present. So I think it's terribly important to establish a climate for policy change in this country where the department of health, the health boards and the hospital boards themselves are convinced and in fact they have to be challenged to open up to the process of negotiation and dialogue with us as the principal stakeholders.

"In principle, other countries are more open, and there's more provision of a range of real choices for women. The specific Irish problem is that we have consultant-led care. We do not have midwife-led care. Studies of midwife-led birth management indicate that when a woman has very good rapport with her midwife, when she has that very close social, personal and psychological support as she goes into labour, she has greater confidence about going through the labour process."

Describing the many potential alternatives to consultant-led hospital-based birth, and writing inspiringly on the confidence that women from non-Western cultures have in their own birth knowledge and power, Murphy-Lawless's book Reading Birth and Death offers a beacon of hope and clarity in a highly political arena.

Reading Birth and Death: A History of Obstetric Thinking is published by Cork University Press.