Can a system designed around support for the masses offer truly individualised care?
To pick apart this question we have to start with one fundamental characteristic of any large system. Guidelines.
When you develop a system to support thousands of women and their babies annually, you need to be able to put some guidelines into place so that the people caring for the users know how to respond when various aspects of their care stray from a predetermined concept of normal. Normal…there’s that word. What exactly is normal?
In all the years I’ve been supporting women, I’ve been listening to birth stories, I’ve been listening to feeding stories and I can honestly say, not a single experience was like another. These stories may have had similarities, but the factors within their stories varied so much that the possible avenues of care were endless. It’s actually why I like doing what I do, because every family I visit with, and talk to, will push me to think of all the different factors and pathways to explore for their particular scenario.
Let’s look at just a few of the guidelines around what we perceive as normal and what determines the systematic care pathways for our birth and breastfeeding journeys.
- a cervix dilates half a cm in an hour, taking longer could be determined as failure to progress
- if your waters go and labour doesn’t commence within 24/48 hours (depending on area) then mother should be induced
- a mother who has reached 41 weeks should be booked for induction
- preventative antibiotics are given to babies in many situations, including Group Strep B and assisted deliveries
- a baby that loses more than 10% of its birth weight will be put on a top up feeding plan
- at 10cm dilation a mother is encouraged and guided to push her baby out
How do these guidelines sound to you? Some may strike you as odd, whereas some may seem like valid reasons to route a mother down a specific care plan. What is the evidence for these guidelines and should they determine how women are moved through the system?
Let’s take a very common scenario that affects about a third of the UK birthing population, the post dates induction. One mother at 41 weeks may respond well to a chemical induction for post dates and deliver her baby within hours of labour commencing. She may also then go on to initiate breastfeeding without any major concerns and have a positive experience all around. Another mother may also undergo chemical induction that results in very slow dilation of the cervix despite extremely painful contractions. Her baby may become distressed, resulting in a cascade of interventions, and a traumatic assisted delivery of baby, who then struggles to latch at the breast.
Which of these women is normal? Could we safely say that the mother who didn’t respond to the chemical induction was abnormal, if the guidelines assume that the average woman should be induced post dates? If we look at the mother who would be labelled as having a “failed induction,” is it possible that her dates were off, or that her baby and body weren’t ready and they just needed another week or two (or more) to begin the process of birth? Did we look at either of these mothers as individuals and consider whether there was a need for the induction? Were there medical reasons causing a concern over the baby, or was it just a guideline that baby’s gestation was 41 weeks and so induction was being offered to minimise the (less than half a percent) risk of stillbirth. When we’re looking at a national induction rate of around 20-30%, many of which are down to post dates, then we have to look at whether we’re considering the individual that we are caring for, or whether we are making a blanket decision based on guidelines framed for an “average” person/birth scenario. And this then brings me to whether a statistic like .3% still birth rate is worth inducing 20% of women over, when it is likely that this will then give you more than a .3% risk of negative birth experiences, including PTSD and PPD. Are we sitting women down and informing them of the risks of still birth, with facts, and then informing them of the risks of induction? When induction isn’t going to plan and the mother isn’t labouring as planned, are we then observing her at each stage and discussing her options at each stage so that she can make an informed decision about what she’d like to do next? Are we having these conversations?
Are we even able to have these conversations? Is it possible for a system that is already stretched thin, both in resources and funding, to assess everyone as an individual? Is there room to incorporate women into the decision making conversations and alter their care pathways to suit their individuality? There’s that question again, “Can a system designed around support for the masses offer truly individualised care?” Do you know what I think? NO. Not where we’re at now. Not when we don’t have continuity of care, not when language used still only serves to coerce a mother down a certain path. Not when so many guidelines still aren’t evidence based and undermine the unique nature of every birthing woman.
Systems for the masses cannot serve the individual.
Women need to take control of their care. They need to know their options in advance, they need to go into birth educated about likelihoods and risks and ready to push conversations with professionals. They need to have birthing partners and doulas who are also well informed and there to support the individual birthing her baby in a system designed around a patriarchal ideal. Because when a woman is a statistical norm framed by a guideline, she will inevitably end up travelling a care plan designed for someone else.