I’m back - book written!
Yesterday, at the invitation of the Royal College of Midwives, I debated with the famous French obstetrician, Michel Odent, “should men be at the birth of babies?” The debate was discussed in the national papers, on the BBC TV news (twice), on radio stations (four times on Radio 5 Live), in the Australian media and yesterday in Time magazine in USA. Two men debating childbirth in front of 400 midwives. One man long enough in his profession to have delivered the other!
Here is my speech - you won’t find anything about what I actually said in the media (a point for later discussion!)
I said:
The best thing ever written on fathers at the birth was written in 1959 in a book Childbirth without Fear by Grantly Dick-Read, one of the most influential thinkers in this field last century. This debate today in 2009 represents our failure to get this issue right for 50 years.
In the 1950s, birth had only recently been taken out of the home. For the previous 200,000 years of human history, mothers were surrounded by loved-ones during childbirth; knowledge about childbirth was embedded within extended families.
Now, suddenly, birth was taken out of the home. Yes, the maternal mortality rate dropped 60 times, but at a price.
Maternity units in those days were pretty gruesome. One of the earliest campaigners for better maternity services was Dr Norman Morris, a Professor of Obstetrics in London. In 1960 in The Lancet he described antenatal clinics as “drab and colourless…with an atmosphere of coldness, unfriendliness and severity more in keeping with the spirit of an income-tax office”.
He describes how women in labour were undressed, shaved, given an enema - and in some places castor-oil - then left alone on a large ward with other abandoned women in different stages of labour, without kindness or sympathy.
He quotes a young mother: “My mental condition was indescribable! I thought all this might injure my baby and they could not be bothered to offer one word of comfort or explanation. From 7am till noon, I did not see a soul. I could not bear my husband near me for a long time after the baby’s birth.”
Most mothers lived then, as they live now, in small family units, with only their partners immediately at hand.
Following the instinct to have someone who loves them at the birth, it was absolutely inevitable that many mothers would want to take the fathers with them.
And still to this day, fathers are there by invitation, as is any other birth partner. It is the mother’s right to choose. And it is our duty to trust the mother’s instinct.
Michel Odent says that mothers are acting according to dogma: the choice to have fathers at the birth is not real, because women do not know what the full consequences of each choice are. He is certainly right about the lack of information, but my proposition is that mothers are acting according to instinct in what is, in human historical terms, a highly unusual situation - the coincidence of institutionalised birth and the division of families into small units.
So what does Grantly Dick-Read say?
First, he saw that what fathers think and do matters. He writes (and remember, he is writing in the 1950s when everyone having a baby was married - supposedly!):
“The importance of the husband’s attitude towards, and understanding of childbirth, cannot be exaggerated. His words and actions, and even the atmosphere in the house that he may create in silence, have a profound effect upon his wife. Her health and happiness during pregnancy, and certainly her approach to labour, will be influenced for better or for worse by harmony or discord that she feels in her husband’s mind.”
I have spent the last 10 years looking at the influence of fathers on maternal and baby health. I organised a major review of evidence when I was at the Fatherhood Institute; and Chester University is about to publish another. And, all the evidence shows that the relationship between the mother and father, and the father’s beliefs and actions and the mother’s perceptions of the fathers’ beliefs all have a profound impact on every aspect of the health of the mother and baby:
* on breastfeeding
* on smoking
* on mental health
* on the mother’s bonding with her baby
* on the mother’s birth experience
So, what about fathers at the birth? Grantly Dick-Read answered the question 50 years ago better than ever I could. He wrote:
“The question that has now occupied so much attention in so many hospital and maternity organisations - ’should the husband be present?’ - depends entirely upon the husband.”
The top priority, says Dick-Read, is for the father not to be ignorant. He writes: “The totally unprepared man has no place at the birth of his child…. If he has not occupied himself to be interested and to have an understanding of childbirth at least equivalent to his wife, he should remain absent until such time as the obstetrician requests him to greet his wife and their newborn child.” These were the days when the obstetrician was definitely in charge!
A father who is knowledgeable, who offers practical help with, for example, breathing and massaging - of these, Dick-Read says: “These men cannot be superseded in the value of their service by the most patient nurse or obstetrician.”
Dick-Read says the surest way to bring peace and confidence is information. The role of the health professional is, “with kindly-stern authority, to urge that the husband learns with his wife, the phenomena and common sense of this natural human function.”
Dick-Read points out that it is not just the ignorance of fathers that can be a problem. He writes: “Mothers, husbands and friends must be recognised as agencies for the production of fear in the minds of the vast majority of young married women…. We recognise that very few daughters learn much that is likely to be helpful from their mothers. The days of large families have passed.”
When it comes to the culture of fear around birth, we are all in this together and we can only get out of it together.
Since 1959, researchers have confirmed everything that Dick-Read has said:
* Women who have a close support person tend to have a more positive birth experience, and that is often the father
* When birth partners, including fathers, know a lot about pain control, women have shorter labours and are less likely to have epidurals
* Practical support is more effective than purely emotional support
* A partner’s fear at the birth increases post-operative pain
So Dick-Read divides men into three categories:
* Men who have learned about the birth and can be helpful and confident. These men should attend the birth.
* But some men try to learn and just cannot overcome their fears. They should not be present: “We sympathise with them” says Dick-Read, “but for their wives’ sake, we keep them downstairs.”
* Men who have not shown interest and are not prepared. They should not be allowed in.
The days when we had the authority to direct parents so definitively have long gone! Obstetricians no longer rule the roost like they did. So the onus is even more on engaging with both the parents and helping them come to the right decision for them, so that labour is shortened and made more positive by the father’s positive contribution - or by his absence.
Michel has also claimed that attending the birth is a major cause of depression in fathers post-natally; and that the impact on the couple’s sex life is commonly negative. No evidence has been found for a correlation between a ruined sex life and fathers’ presence at the birth; and a study in 2000 by Greenhalgh and others found that any correlation between negative birth experience and fathers’ depression in the postnatal period disappeared once pre-existing depressive symptoms were controlled for.
As I am sure you are told repeatedly in your training: “correlation does not imply causation!” Men are present at the birth - yes. Postnatal depression in new fathers is a real problem - yes. But the evidence does not demonstrate that one causes the other.
So why are we still stuck 50 years later discussing this issue? For something to be stuck that long means there is an underlying problem that we have not perceived or addressed.
At the heart of the problem is that the NHS is structured to deal only with “patients” and “visitors”, not with a natural family event such as a birth. Only mothers are registered with the health service. The NHS only has a formal relationship with the mother. The NHS will only talk to mothers - like the recently republished NHS Pregnancy Guide, which comes across as horribly patronising to fathers.
This approach simply cannot work for midwives, because you are eyeball to eyeball with fathers every day, however much the system pretends they are not there at all. The Royal College of Midwives once issued a statement that comes from the midwife’s particular exposure to reality on a day-to-day basis: the birth of a baby is also the birth of a family.
In honour of the 50th birthday of the final edition of Grantly Dick-Read’s Childbirth without Fear, Family Info is today launching a new edition of the Dad card with revised advice for fathers attending the birth, based exactly on what Grantly Dick-Read said. Fathers should make sure they know what their role is. And they should consider not being at the birth if they really don’t think they can play this role. They should ask the midwife for information and advice on this. The card will be distributed by midwives to 600,000 families a year, following Cathy Warwick’s call to all maternity services to distribute it. The Dad card backs the RCM’s Normal Birth Campaign - because without the support of fathers that campaign cannot succeed.
Today the Conservatives are announcing, at this conference, their new maternity policy. It includes the proposal that the standard care pathway should include at least one antenatal appointment where the father is specifically invited to attend and where the issue of his influence is discussed with both mum and dad - his influence on breastfeeding, mental health, smoking - and above all, his role at the birth.
This would be the first ever formal engagement of maternity services with the family of the mother. It would require defining procedures, measuring performance and ensuring the necessary skills. All for the first time.
This is directly in line with the Nursing & Midwifery Code of Conduct for Midwives, which states that midwives, as health professionals, must “work with others to protect and promote the health and wellbeing of those in your care, their families and carers”. The Code states also that midwives must deliver “care based on the best available evidence or best practice”.
I want to end with a story.
I took my young daughter rock-climbing recently. Before she set off up the rock face with me hanging onto the end of the rope, I received 15 minutes of instruction - how to hold the rope, how not to get it trapped, how to provide the right kind of support to my daughter on her way up and on her way down. There is no way I would have put myself in this position without knowing what I was meant to do and feeling confident that I could do it. I could really hurt her through my ignorance. Birth is just the same - I need some instruction and without it, I am at risk of causing pain and misery.
My knowledge of rock-climbing up to that weekend away was absolutely zero - I had hardly done it before and I did not come from a family with lots of rock climbers. Dick-Read wrote in 1959: “the ignorance of the average man about childbirth is incredible”. And it is still the case today; just as most people have no idea about rock climbing. So, we fathers need the basic training so we do the right thing.
Thank you for choosing to be midwives. It is the most wonderful job. Remember Grantly Dick-Read’s words:
“Your concern is not only to see the child into the world but also to enable these two people to be united in the most wonderful, awe-inspiring experience that can possibly fall to the lot of wedded human beings.”
You will see more fathers than any other health professional or social worker or teacher. But the NHS has not given you the tools you need to do the job you have to do. I hope that can change - and in less than 50 years more!
Parenting together
birth, Fatherhood, maternity, motherhood
At the weekend I went to the demonstration in London against the destruction by King’s College Hospital of the Albany Midwives, a beacon of family and community based midwifery. I even spoke at the demo from the top of a double decker bus in front of the Department of Health - the listeners were certainly a lot more responsive than at any of the many meetings I have been to inside the Department!
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