Catalysis with MOFs

If cervical treatments have an effect on labour, then this leads to an effect on women and the way they perceive their labours. From the woman‟s point of view, progress in labour, interventions in labour and instrumental births are as important as the outcome. Not only have interventions, and instrumental births, been shown to decrease women's satisfaction with their birth experience and increase the length of hospital stays, but they are identified as predictors of Post Traumatic Stress

Disorder (PTSD) and Postnatal Depression (Prince and Adams 1987; Creedy, Shochet et al. 2000; Soet, Brack et al. 2003). The literature on women‟s experiences is arranged to follow the themes present in the women‟s stories of their births in the study, to allow easier cross referencing.

Chapter 2 LETZ and progress in labour

2.4.1 Negative language/attitudes and feelings of failure

Research has shown that many women feel inadequate giving birth. Women‟s perceptions are that they are not adhering to the „norm‟, and this is partly due to the language used by midwives and obstetricians. Research on language used in

labour, reveals that negative language decreases women‟s self esteem and ability to cope with labour (Bastion 1992; Zander 1997; Fowles 1998; Green and Baston 2003; Kitzinger 2004). Negative medical language affects not only the kind of care received, but also how women think about and experience their bodies. Kitzinger (2005) describes some of the language used; that the woman‟s cervix is „failing to dilate‟ or „not performing‟, so medical staff prescribe oxytocin that stimulates the uterus further, which enhances labour or makes it „perform‟ better. As LETZ alters the functioning of the cervix, these women could be subject to negative language.

This language is often proscriptive and can appear threatening to women, as in the following quotes from calls to a helpline, which was set up to help women talk out their feelings after a bad birth experience -

“I was told I could kill my baby”

“„It was my fault because I didn‟t push hard enough”

“I couldn‟t move. They said I had to lie on my back. When I moved it interfered with the print-out from the monitor”

(Quotes from women who called the Birth Crisis helpline (Kitzinger 2004)

Simkin (1996) finds that negative caregiver attitudes result in a more negative image for women after birth, and positive attitudes result in a more positive self-image. This is especially important, as Waldenstrom (2003) claims that the negative events around birth increase in significance over time, whereas positive aspects stay the same. In a study analysing a convenience sample of 15 women‟s stories, Vande-Vusse (1999b) states that when decision making is unilateral by the caregivers, women are more negative about their birth experience. Green and Baston (2003) define negative attitudes as staff being unhelpful, rude, offhand, bossy, insensitive, inconsiderate and condescending or any selection of these.

Although they state that negative attitudes do not affect women‟s feelings of control, they find that positive attitudes, defined as being treated with respect and consulted about options, do. It is perhaps a flaw in their questionnaire-based research that these aspects, that are mirror images of each other, do not reflect the same results on feelings of control.

Chapter 2 LETZ and progress in labour

From a convenience sample of seventy-seven women, nine weeks postnatal, Fowles (1998) finds that women are frustrated about; their lack of control in labour, feeling vulnerable in labour, lack of knowledge of what actually happens in labour (how to push, posterior position labour, induction), and negative perceptions of health care providers (perceived rude behaviour, uncaring interactions and

undesired actions). As in this woman‟s experience of VE, reported in Vande-Vusse (1999b) study of women‟s own birth stories in America, who still has unresolved negative emotions about the birth while preparing to have her next baby –

"...he put his hand inside the vagina to see everything's okay. I

understand that. But, it was so uncomfortable. And I said, Please don't do that, it hurts! He didn't say anything; he just got up and sat

down... And then I thought, Oh! I offended him...after I listened to this (recording), I thought, how, why was I so polite? He was actually unpleasant a couple of times, just in this real short time

that he was there"

(Quote from a woman in Vande-Vusse 1999b, p.45-46)

Women‟s control may be decreased by the affect of LETZ on the cervix resulting in their labour being defined as „abnormal‟, and this can lead to decreased satisfaction with the birth experience. Decreased satisfaction with the birth experience is a contributing factor in postnatal depression (Prince and Adams 1987). In a survey of one hundred and three women in late pregnancy, with follow-up interviews

approximately four weeks postnatal, Soet, Brack and Dilorio (2003) find 30% of women are partially symptomatic for PTSD. CEMACH (2005), identifies suicide as the leading cause of maternal death, and the latest figures show that cardiac problems have just overtaken suicide (CEMACH, 2007), leaving no doubt that psychological morbidity in childbearing women is a significant and pressing issue.

2.4.2 Pain relief

Windridge and Berryman (1999) find that women aged 20-29 years report that caregivers intervened in a way that worsened pain, i.e. in being asked to move into certain positions, for VE or EFM that are uncomfortable, or increase the severity of their pain. Soet, Brack and Dilorio (2003) conclude that pain experienced during the birth is a significant predictor of PTSD symptoms, especially pain during the 1^st stage of labour. Green and Baston (2003) state that the ways women are helped to deal with pain, affect their perceptions of control. Conversely, McCrea and Wright (1999) find that feelings of personal control influence positively the women's satisfaction with pain relief during labour.

Chapter 2 LETZ and progress in labour

Cunningham (1993) finds that women, who use pain relief, express considerably fewer positive feelings about their birth experience than their peers. In a survey of 295 women‟s experiences in Sweden, Waldenstrom, Borg, Olsson, Skold and Wall (1996a) conclude that women usually experience severe pain, but despite that most are satisfied with their own achievement and think they have coped better than expected. These findings show that a positive birth experience does not necessarily preclude pain and distress and confirms the multidimensional character of the birth experience. It also shows that women's assessment of their labour is influenced by both physical and psychosocial factors, which highlights the importance of a holistic approach to care in labour.

2.4.3 Interventions lead to negative feelings

The research literature is ambivalent about the effect of the number of obstetric interventions. Green and Baston (2003) state it has no effect on women‟s feelings of control while Creedy, Shochet and Horsfall (2000), Soet, Brack and Dilorio (2003) and Fowles (1998) contradict this. Kitzinger (2005), talks about the „cascade of intervention‟, the application of one intervention leading to other interventions. Such as, obstetric staff prescribing oxytocin to stimulate the uterus further and bring the labour back to the „normal‟ parameters. This leads to mandatory use of EFM and increases the severity of contractions. Increased severity of contractions leads to a greater need for pain relief, often an epidural. Epidurals lead to more Instrumental births by forceps (Illuzzi, Magriples et al. 2003) or CS (Fusi, Steer et al. 1989; Goetzl 2008; Steer 2009). Electronic Foetal Monitor use leads to an increase in

Instrumental births, and increase in CS (Walsh 2008). Instrumental births by forceps lead to episiotomies, which lead to perineal suturing. Caesarean Sections lead to abdominal wounds, catheterisation of the bladder, and longer recovery time from the birth.

Creedy, Shochet and Horsfall (2000) find women with high levels of obstetric intervention and dissatisfaction with their care, are suffering PTSD, findings echoed by Soet, Brack and Dilorio (2003). Creedy, Shochet and Horsfall conducted

telephone interviews with 592 women 4-6 weeks postnatal, and conclude that approximately 1 in 20 women are suffering PTSD, while a third have some of the symptoms, a finding confirmed by Soet, Brack and Dilorio. Creedy, Shochet and Horsfall also find that Instrumental birth by forceps is as traumatic as CS for women,

Chapter 2 LETZ and progress in labour

and that a highly significant correlation between high levels of obstetric intervention and low levels of satisfaction with care, increase the likelihood of acute trauma symptoms after birth. Their solution of preparing women more fully, for the types and levels of interventions in use, seems a complicit acceptance of the obstetric

technological model of birth. No mention is made of modelling more holistic care that reduces the level of interventions. No research is found in the literature review on women‟s feelings about the intervention of LETZ; negative feelings may be reinforced by further intervention and negative language.

2.4.4 Positive language/attitudes from others

Vande-Vusse (1999b) finds that when decision making is shared, women have a more positive view of their birth and Fowles (1998) finds that women identify midwives, husband, „staff‟ and doctors as those who help make a positive birth experience, findings confirmed by Fisher, Hauck and Fenwick (2006). Dzakpasu and Chalmers (2005) state that continuity of care is important to mothers.

Cunningham (1993) concludes that of midwife attended births, 61% rate midwives as high as possible for support and encouragement, and 63% rate midwives as high as possible for contributing to their feelings of wellbeing.

2.4.5 Loss of control/power

When medical staff in a North American hospital are asked to define a 'good patient‟

one doctor answers - ”She does what I say, hears what I say, believes what I say”

(Kitzinger 2004). The emphasis is that a good patient is compliant; she thanks the professionals because they „save‟ her baby and she is grateful regardless of what they do to her. Green and Baston (2003) sent questionnaires to 1146 women one month before birth, to assess their preferences and expectations and again at 6 weeks after birth, to discover their experiences and assess psychological outcomes.

Whether they already have a baby is strongly associated with feeling in control, with women having their first baby feeling less in control, than women having other births. Feeling in control of what staff are doing, is associated with fewer depressive symptoms after the birth, for both women having their first birth and women having other births.

Chapter 2 LETZ and progress in labour

Women who have to contest medical decisions, or adapt to them when they do not agree with them, are more negative about their births (Vande-Vusse 1999b). As in this woman‟s experience -

"I mean, we had talked all this over before. And she agreed to

everything that I had wanted. Then, at the time of the birth, actually things were a little bit different than I had authored. I was stuck in

that bed because of the monitor being there."

(Quote from a woman interviewed in Vande-Vusse 1999b, p.47).

Loss of personal control is identified as the main factor in fear of childbirth by Fisher, Hauck and Fenwick (2006) and is a major concern of postnatal mothers in the study by Fowles (1998). McCrea and Wright (1999) find that being in control is often associated with satisfaction with pain relief in, but loss of control does not always equate to loss of power, as Davis-Floyd (1994) reveals many women feel that strength and power come from relinquishing control to the birth process.

2.4.5.1 Relinquishing responsibility and control to authority

Davis-Floyd (1994) documents how women absorb the prevalent technocratic hegemony, and how this translates into their acceptance of someone else, the obstetric authority figure, being in charge of their labour. Kornelsen (2005) study into technology in birth confirms this view. Medical management of labour decreases the control experienced by birthing women, creates a power imbalance between the woman and the midwife/obstetrician, and deprives the woman from a potentially empowering experience.

Kornelsen, in a non-random sample of 25 home birth mothers, and 25 low risk hospital birth mothers (several of whom wanted a natural birth), finds that hospital birth mothers feel they are „flexible' about obstetric technologies, but that flexibility is a double edged sword. An efficacious strategy when approaching new and unknown situations, it also creates an opening for the imperatives of technology, and a more extreme form of flexibility results in the relinquishing of responsibility and control to medical practitioners. Kornelsen contends that at the heart of a woman‟s ability to question, is the ability to conceive of an alternative and that alternatives are not often presented to labouring women, they are only presented with the established practice. Women who have LETZ are only presented with the established practice;

as to date no research evidence shows the patterns of their labours are affected.

Chapter 2 LETZ and progress in labour

Vande-Vusse (1999b) reports that many women relinquish control to authority, on the assumption that caregivers' professional knowledge and technological expertise are superior to their own innate knowledge, a view echoed by Harrison, Kushner, Benzies, Rempei and Kimak (2003). Women report numerous instances of control in their birth stories, predominantly exercised by the health caregivers, particularly through the application of various obstetric technologies and procedures.

Sometimes that control is reluctantly given as in this woman‟s experience of EFM –

"I said, Why, I can take the cords with me, and they wouldn't let me....I had to use a bedpan. And that upset me... I had to have a bowel movement, so I had to sit up; meantime, the IV is getting all messed up, the blood is coming through the tubes...I'm crying, Just

let me go to the bathroom. No, they wouldn't let me...."

(Quote from a woman in Vande-Vusse 1999b, p.46)

2.4.5.2 Helplessness

Many women feel helpless in their lack of knowledge, about specific problems or procedures, during and after childbirth (Fowles 1998), and feelings of helplessness or powerlessness are significant contributors to PTSD symptoms in the study by Soet, Brack and Dilorio (2003). In a study of 22 women by Fisher, Hauck and Fenwick (2006), women feel helpless due to - fear of the unknown; horror stories;

general fear for the well being of the baby; fear of pain; losing control and disempowerment; and uniqueness of each birth.

2.4.6 Intuition

Some women follow the „alternative ideologies‟ to the prevailing technocratic birth.

These women believe that themselves and their baby are one, (that is they do not believe in the mind-body divide that is central to Western medicine), are more likely to believe in their power to give birth and to listen to their intuition or „birthing force‟

(Davis-Floyd 1994; Viisainen 2001; Kornelsen 2005). Most of these women choose to give birth at home. These women feel deeply that female physiological processes, including birth, are healthy and safe, that mother and baby are one and that there is an inner knowing that can be relied upon during their births (Davis-Floyd 1994).

These women often regard their intuition or „inner knowing‟ more highly than the medical authoritative knowledge. None of the women in the study by Davis-Floyd (1994) who chose to give birth in hospital report much respect for or reliance on their own intuition or „inner knowing‟.

Chapter 2 LETZ and progress in labour

In Kornelsen‟s study the intuition is rephrased as the 'birthing force' ((Kornelsen 2005). Many of the women in that research study who plan to have home births saw birth as the link between their internal and highly individual processes and a „birthing force‟. Some refer to a kind of inner logic within the birth process that is beyond understanding. All of these women describe something that has its own reasons, a force greater than women, even if, as is the case in childbirth, it is realized through women and is a resource for women during birth. Kornelsen indicates that fear and pain are affected by acceptance of and surrender to the „birthing force‟.

Viisainen (2001) is another researcher who also stresses the importance of intuitive knowledge during pregnancy and women being able to trust their intuitive

knowledge and trust their ability to give birth. Trusting their ability and intuitions and being in control are key determinants of a `natural' birth in the women's stories in her study. The atmosphere at the woman‟s own home, the presence of the husband, family and an experienced midwife, all help women to trust their own abilities. One woman is astonished by her own strength -

“One thing that became clear to me in this birth is that I gave birth trusting my own strength. We have such powers inside if we only knew how to use them;

So that we would dare to go against the directions given by society and do what we feel is right.''

(Viisainen 2001, p.1114)