Frederick Leboyer on Woman's hour today on childbirth without intervention

[queenceleste]

listen again here.

Amazing considering he's a man, he was one of the first promoters of waterbirth.

Jane Garvey obviously totally disagrees with him but it's all in her tone...

I heard the last five minutes of this man talking twaddle. I found myself shouting at the radio at one point. What was it he said about babies in breech position? Something about the mother not being relaxed enough? And that if she was more relaxed the baby wouldn't be in breech position? Try telling that to cows and ewes that present with a breech position calf or lamb. This is a short part of the interview. See if anybody can make head or tail of what this man is saying:

Jane Garvey: I had two elective caesareans because both my babies were breech babies.

Leboyer: That?s a complete mistake. Breech is normal.

JG: So what should have happened?

L: But what is wrong with breech? ? it is a normal physiological posture of the child during the last month of pregnancy?. but If the woman is too tense and too much afraid then the child cannot move?the thing to be done would be to make the woman free from her fears. If she would face her fear instead of running away she would say yes I?m afraid?.if she would look her fear in the eye it would vanish.

JG: But we know hundreds of thousands of women, all over the world, some in very poor countries, die in childbirth.

L: No that?s not true! That?s a lie, a lie. What you?re saying now is a sort of excuse for what you?ve been doing but there?s no guilt. Fear plays such a great part. All I?m telling I learned it from women. Childbirth is a secret garden of women.

JG: Is there in yr opinion any case for medical intervention?

L: Only when it goes wrong! But first you?ve got to try. At a certain point of labour woman is experiencing death and because she?s been able to face death she becomes free from the fear of death.

JG: Is there anything positive about our current experience?

L: No there is nothing positive it is all wrong. Completely wrong. If you?ve decided you?re not going to take any risk then you are really in danger. And childbirth is complete risk. You are put on your mettle. Either you take the challenge or you chicken out.

I mean, what??? It's a LIE that hundreds of thousands of women in very poor countries die in childbirth? Isn't that what used to happen in this country before medical intervention became the norm for women having problems?

He is right at the outside of the non intervention end of the spectrum, Ill give you that!

But, I do think the truth is somewhere in the middle of our massively intervened hospital births and a supported home birth. Obviously women would range between the two extremes but it would be nice if there could be more flexibility in the system.

Of course we all want help when things go wrong but what is now hard to see are the problems created by intervention rather than solved by them. There is a lot of intervention that is probably unnecessary because of risk aversion from parents and professionals. That is where we are, but many would argue that something precious is lost in that exchange. For some that's fine, for others it's tragic.

Breech births used to be treated as normal and medical staff were good at delivering them, my sister was a mw and breech births were not automatic cs. Statistical risk has led almost all breech births to be automatic c sections so the skills are lost from what I understand.

I agree he sounds odd in his language but I think what underlies his position is that the woman is far more powerful in the whole process. Having delivered my dd virtually on my own after falling out with my mw and the obs I sort of know what he means in my case. I wanted to be supported to have the baby where I was comfortable but they wouldn't let me! I've met many women who have had homebirths and they most talk about how being in charge of their space made a profound difference to the experience. I also have a friend who had two waterbirths at home with and independent midwife who is also a close friend. She described an almost ecstatic experience. So I sort of know what this man is getting at. He's saying that the usual hospital birth is a million miles from what it could be in many cases. I must say I broadly agree with him ime. But there's no criticism of anyone in this system, we have the benefits and the losses inherent to it. And more live births per 1000 is a massive benefit of course! But it comes at some cost to the interference with very many potentially normal births.

"I mean, what??? It's a LIE that hundreds of thousands of women in very poor countries die in childbirth? Isn't that what used to happen in this country before medical intervention became the norm for women having problems?"

No. The maternal death rate in the UK was very low in the 1940's and 1950's, when most women were still giving birth at home and when the c/s rate was less than 5%. Women who die in childbirth in developing countries don't just lack access to doctors. They will often lack access to the most basic screening in pregnancy, the care of midwives, and decent nutrition. Some already have health problems when they become pregnant because of lack of prior medical treatment. That was true in the UK in the very early part of the last century, but even then our maternal mortality rates were never remotely as bad as they are in Afghanistan today......

queencelest, I'm with you. I haven't listened to the whole interview but I understand what Leboyer is referring to in the bit quoted by the OP - about female power and autonomy in childbirth.

The remarks about breeches really rile me. My first Ds was breech and it was due to him being completely tangled up in his cord and we have both been dead without the evil EC!

i thought he sounded a bit bonkers however i remember hearing a r4 doc about a scottish midwife who had delivered gazillions of children in the 30s, 40s and 50s and as an old woman she wept at what she had had to do to women when birth started to move into hospital.

I think anyone who's read about the type of midwifery they practice on The Farm, and looked at Ina May's stats will find it hard not to arrive at the conclusion that millions of women are being unnecessarily damaged in childbirth in our current system.

"The remarks about breeches really rile me. My first Ds was breech and it was due to him being completely tangled up in his cord and we have both been dead without the evil EC!"

The thing is ajmama - there are NO certainties in childbirth. If you go back through historical documents and look at midwives' records from the last century you see that there are some midwives who delivered over a 1000 women - including all sorts of difficult cases like breech and twins, and never lost a mother. Ina May's statistics are amazing - I think they've got a 1.5% c/s rate at her birth centre (over 2000 deliveries) and they've safely delivered twins, breech babies, face and brow presentations (considered 'unbirthable' vaginally everywhere else) with lower infant mortality rates than hospitals.

Not arguing that all babies can be delivered safely vaginally, but I suspect a good number of babies currently being born by c/s could be born safely vaginally, if doctors, midwives and mothers were not so risk averse. (not saying they shouldn't be risk averse - totally understandable, but it's the fear of a poor outcome that's driving the rising tide of surgery, not the fact that 27% of babies are currently unbirthable vaginally)

my sister was a mw in the 80s and saw an Egyptian obstetrician deliver a face presenting baby (that's not accurate term but it's a description) and my sister said he was amazing, he'd learned to deliver every kind of baby and was incredibly confident because he'd done so many.

How can any midwife or dr in our system ever learn any of these specialist skills when the system is in its very bones risk averse? I'm not saying they shouldn't be, I'm just saying there are other losses.

And women who tear badly (some would argue through inappropriate intervention, poor care, poor education) and are repaired poorly, then what price do you put on your future sex life? There are so many variables here and the cost is hard to calculate. But I know if I had been younger and braver I would have loved to have had a homebirth, I know there is great risk but hospitals produce their own massive risks as well!

of course, I want to add, c sections are absolutely necessary for many births. But there's no question that we have a c section rate that reflect medical risk aversion rather than statistics for women who all need this level of intervention! I don't think anyone would disagree with that.

If the aim is that both mum and baby are healthy and alive after delivery then medical itervention is fine. I think women should be helped to have the birth that they want - whether this is natural or otherwise. Always wary of people who have not personally experienced birth providing a dictate to those who have. It is a personal experience for which most women are aware of risks and impact of interventions.

Are Ina May stats clean from reporting bias etc, though?

Yes but it isn't that simple.
The Portland Hospital at one stage had the highest maternal death rate of any London hospital hmm... interesting.
I know that's partly because they have no AandE there and are oddly staffed in some ways but it isn't as simple as you say.
The structure of risk aversion precludes other forms of childbirth ipso facto other problems are created and yes, some fatalities probably happen because they are avoiding fatalities.

The obstetric and surgical professional community have everything to gain from making childbirth an entirely manageda experience removing even lowrisk mothers from homes and birth centres and away from mw support.
It's really hard to have a home birth now because of staffing.
It's really hard to use a birthing suite in a hospital because of staffing.
If you're a surgeon or obstetrician you're still holidaying in Tuscany while mws lose their jobs and women find it harder and harder to have more natural births supported at all except in a very few places. It is, in my opinion, an effectively misogynistic system if no intentionally so.
This Frenchman has a point and remember he says very clearly that his knowledge is based on what women have told him plus countless births attended and from a medical perspective. He's not some Know Nothing.

Also, you can only find out retrospectively whether a vaginal birth of an awkward presentation would go right. The risk aversion is, in my opinion, not just a thing about not wanting to be sued. Of course doctors don't want to be sued - but behind every lawsuit for a birth gone wrong is a damaged or dead baby and/or mother. Isn't it natural to want to avoid such outcomes.

If a CS is statistically safer than a VB for breech, is there really any value in holding on to the breech VB, or is it just nostalgia?

To say "but it's the fear of a poor outcome that's driving the rising tide of surgery, not the fact that 27% of babies are currently unbirthable vaginally)" sounds rather cold to me and glossing over the fact that "poor outcome" means "dead or badly disabled baby". I'd say a good outcome should be the No 1 priority.

Totally agree with Boogiemumma. It is all down to personal choice, I could not think of anything worse than having attempted a breech delivery or by a midwife like Ina May but the choice should be there for those that do. Most of my friends like myself delivered at the Portland and all of us who had breeches were offered a trial of labour and one successfully had a vaginal breech birth.

Widowers an, Ina May Gaskin is such a high profile midwife, and The Farm is the most famous birth centre in the US. I think if her records were really unreliable someone would have unearthed something by now. It wouldn't take much. I suspect she's a hate figure in some US obstetric circles as she's been so critical of American maternity care. I'm sure if there was dirt to dish on her it would have been done by now.

Ok for the sake of argument say that you now supported a totally homebirth based system well staffed and with high funding for taking any difficult births into hospital.

If the consequence was women had fewer interventions, far less traumatic births, happier mother baby bonding, better chance of supporting bf for those who want it, massive cost savings. etc etc.
I wonder whether there would be that many more maternal and infant deaths? And if there was a big improvement in the physical and mental health of our infant and maternal population maybe that would have a comparable value to a tiny shift in infant/maternal mortality?
I just think childbirth for most women can be normal if treated as such and approriately supported.
obviously this is only a sketchy hypothesis but it's amazing how positive women are about births which they were allowed to manage themselves with support.
I'm not suggesting there should be no csections or interventions but there should be far fewer imo. Particularly as we know that the more you intervene in labour the more interventions there will be in each case. this has been proven fairly clearly I understand.
But it's all academic, we are where we are and everyone seems to be sacking midwives, I guess that hurrah for the obs and surgeons, but tragic for the vast numbers of women who are low risk, imo.

Ajmama Im not sure that free choice exists in a system dominated by fear, an entrenched tradition of medicalised birth, and restricted by insufficient resources. An example of this would be the issue of homebirth. Most women in the uk see hospital as the safest place to have their baby, despite the lack of good evidence that this is the case, and the mounting body of evidence that women are more likely to have longer, more painful and more difficult births in these settings.

Women are not 'free' to choose a homebirth if they've been indoctrinated from childhood to believe that the only safe place to give birth is in hospital.

Spudulika, anyone can have a homebirth in the UK if thats what they want, OK its not ideal if you have to pay an independent midwife but the choice is there. We are all grown ups when we have babies and it is ridiculous to say that most women have babies in hospital because it has been indoctrinated into them that its the safest since childhood. You only have to look at the childbirth threads on here to see that scores of women want an EC and are looking for support in getting one. I dont want to get into a home/hospital argument but through maternal choice a majority of women still want a hospital birth with medical back up and we are very lucky in the western world to have choices. Ask a woman in Africa with a fistula or a PPH if she would like a homebirth the next time. The choices are there for us and we should just all shut up and respect an individuals choice.

"The choices are there for us and we should just all shut up and respect an individuals choice."

Sorry, but when the "choice" is being pushed into something unnecessarily (in my case ELCS which I resisted and in the end was told I didn't even need after being told for weeks I "had" to have one) means that nobody in the same situation ever gives birth vaginally anymore, so that there are NO medical staff who know how to hande it, there IS no individual choice. Feeling as though you can't give vaginal breech birth a try because nobody will know how to deal with it means your ELCS isn't really a choice now, is it?

The various registrars and consultants I've dealt with couldn't even give me the statistics of women giving birth with low-lying placenta (my condition) because it's blanket policy for the hospital to require an ELCS for it. I took one look at the risks for ELCS vs. what the medical journals and even RCOG had to say about my low-lying placenta and said no thanks. And a few weeks later, here I am planning the homebirth I wanted in the first place. Could have done without all the fear-mongering and stress though.

Making decisions based on blanket policies rather than individual women's situations surely makes a mockery of this so-called "respect" for "an individual's choice" don't you think? I'm all for choice, but it needs to be true choice, based on the individual's need, not because the system can't handle it, the staff doesn't have the experience, the doctors are afraid of getting sued, or some policy-maker came up with an arbitrary cut-off mark for whatever condition they're dealing with.

In my experience that's not what happens. I went into this pregnancy very hopeful and open-minded and I've been left feeling mistrustful of the medical system and doctors after being told one too many contradictory and patronising things. Haven't even given birth yet! So yeah I'm a bit angry about it. The kind of crap I've gone through shouldn't happen.

"Spudulika, anyone can have a homebirth in the UK if thats what they want",

So the fact that only 2% of women nationally have one is indicative that the rest are a) aware that homebirth is as safe for low risk mothers as hospital birth b) confident that it's a reasonable choice?

Because when I had my first nobody mentioned it to me as a possibility and I was of the view that it was a very radical, 'fringe' choice that only a certain 'type' of person would go for, and that person wasn't me.

What changed my mind about homebirths was meeting a midwife who was supportive and proactive about birth outside hospital. Also knowing other women who'd had their babies at home.

"OK its not ideal if you have to pay an independent midwife but the choice is there"

What, even for mothers on benefits?

"but through maternal choice a majority of women still want a hospital birth with medical back up"

But that's because homebirth is still seen as a radical choice, and most women believe that hospital is safer. It's not a choice rooted in an objective understanding of the facts. Women are being influenced in their birth choices by prejudice, fear, and by tradition.

Oh, BTW, women who have their babies at home have 'medical back up'. In choosing a homebirth you're not signing off your right to an epidural, to a c/s or to help from medics, should you end up needing it.

"Ask a woman in Africa with a fistula or a PPH if she would like a homebirth the next time"

Oh come on - you're assuming hospital birth as the 'default mode'. What women in developing countries want is good quality, affordable care, and that may well be the sort of care that comes from a properly trained midwife in their community with back up obstetric services. You're assuming that what we should be striving for in these countries is what we have here - 98% of women giving birth in hospital and high rates of intervention. What a disaster that would be - because it would be unaffordable and would be throwing the baby out with the bathwater.

Would add, the homebirth rate varies from 0.2% to more than 10% nationally.

That variation alone points to inconsistent strategies being used to make homebirth more widely available.

The Healthcare Commission survey which was done in 2007 found collossal differences in what choices women were presented with when it came to place of birth.

In South Devon 92% of women were made aware of the choice of homebirth.
Compared to other hospitals where just over a third of mothers were told about this option.

New York midwives lose right to deliver in the home:

here

Hungarian midwife, champion of homebirth, sentenced to two years in prison.
here

If you think the obstetric community want to support homebirth then read the above. This represents a much wider hostility to the midwifery profession and consequently for uninterfered with labour.

Queen Celeste - in the US midwife doesn't neccessarily mean the same as midwife in a UK context, there's different types, and not all of them are trained/qualified to an adequate standard. It's a bit more complicated than just an evil obstetricians vs good midwives thing.

As far as your points regarding bonding, breastfeeding, mental health are concerned - they are all important, but promoting vaginal birth as the only or best way to achieve this, is in my opinion barking up the wrong tree.

Why are women made to feel like failures when they need help in the shape of instrumental delivery or CS? I don't want to downplay that an emergency situation in which this is needed is traumatic, I'm sure it is, but I also think often too much emphasis is put onto the method of delivery.

If you tell a woman often enough, especially in a vulnerable postnatal stage, that she missed out on something and that you feel sorry for her, rather than celebrating the fact that she had a healthy baby, than I'm sure that won't do her mental health any good.

If you tell someone that a CS affects bonding negatively and makes breastfeeding difficult, then they might start believing it. How about just providing breastfeeding support (if wanted/needed) without any reference to how the baby has been born?

I don't think we should build natal services around the feelings of one group of women who have a particular outcome.

We surely shouldn't be aiming for 100% c section deliveries should we? I can't believe we could afford that as a nation!
But seriously no one should make a woman feel at all inadequate for what happens but if that means we're not allowed to talk about the benefits of bf for example than that's a bit mad isn't it?
I think, and no disrespect to anyone who has had a cs, that there are many advantages to a vaginal delivery if it's appropriately supported.
It is how we were designed to give birth, or is it not ok to say that?

"in the US midwife doesn't neccessarily mean the same as midwife in a UK context, there's different types, and not all of them are trained/qualified to an adequate standard. It's a bit more complicated than just an evil obstetricians vs good midwives thing."

All midwives entering training in the UK will now do 'direct entry'. In the past many did a 3 year nurse training followed by an 18 month midwifery specialism.

In the US most states ban direct entry (or the US equivalent) from being the lead professional in the birth, despite the fact that it's a normal pattern of care in the UK and across much of Europe, Australia and New Zealand.

The only way to practice midwifery in most states in the US is to be 'nurse midwife' certified.

How can it be that the majority of midwives in the UK would not be deemed properly qualified to work in the US system?

And that women who are having the most expensive care in the world from doctors are having such poor outcomes compared to women having much cheaper care, provided by midwives in other countries?

"Why are women made to feel like failures when they need help in the shape of instrumental delivery or CS?"

Who makes women feel like a 'failure' if they need help in childbirth? Pointing out the institutional failings that are leading to phenomonally high numbers of women needing medical assistance to give birth is doing the exact opposite - taking the blame off individual women, who are all doing their simple best during what for most of us is a very difficult experience, to get a healthy baby born, however that happens.

" I don't want to downplay that an emergency situation in which this is needed is traumatic, I'm sure it is, but I also think often too much emphasis is put onto the method of delivery".

I completely disagree. When unnecessary and avoidable major surgery is being done on helpless new mothers because of the structural and economic ideosyncracies of the system of healthcare they are using, then we all ought to be flagging it up as a concern.

What the heck do the benefits of breastfeeding have to do with mode of delivery? And who said a 100% CS rate is desirable?

And what do you mean by "I don't think we should build natal services around the feelings of one group of women who have a particular outcome. " when you earlier argued that a few dead babies and women might be a price worth paying for the allegedly improved mental health of women who give birth without intervention?