Gestational Diabetes, Induction, over-use of intervention and the history of birth.
In Episode 30 of my podcast, Birth: the forgotten feminist issue, I interview Dr Rachel Reed, author of midwifethinking blog. We discuss the all too common "diagnosis" of Gestational Diabetes, and how this affects a woman's treatment pathway, often leading to induction, women being treated as a source of risk for their baby, and the cascade of intervention. Rachel explains how so many women have come to be diagnosed with Gestational Diabetes, why else we're seeing so many women having an induction of labour, medical risk, and birth trauma. We discuss the ceremonial practice of birth, the "identity crisis" midwives are currently going through, and why birth is the forgotten feminist issue.
You can read more from Rachel at her blog midwifethinking: MidwifeThinking
Her recent books are: Why Induction Matters and Reclaiming Childbirth as a Rite of Passage
She also co-hosts the podcast The Midwives' Cauldron
You can see Dr Rachel Reed formerly from USC’s School of Nursing and Midwifery was interviewed for Birth Time: The Documentary. She states:
“In Australia we have a heavily medicalised maternity system that leads to a lot of interventions for women, many of whom do not particularly want or need them,” said the Senior Lecturer in Midwifery.
“There have been reports of coercion and manipulation. Often, it’s not done intentionally – rather more as an attempt to mitigate medical risk. But what is not counted is the emotional risks facing women if they experience disrespectful care.
“Birth trauma is not about how a woman births. It’s about how she was treated during birth. There’s more to trauma than a physically traumatic experience.”
Unknown Speaker 0:00
Welcome to Episode 30 of birth the Forgotten feminist issue today with me, I've got Dr. Rachel Reed. She's an author, and midwife. She's been a longtime as a midwifery lecturer at university as well, and you've taught in, not taught, but you've been practicing as a midwife, previously in the UK as well as Australia. And I know I've listened to speak about quite the contrast between the two maternity systems. One of the fascinating things that I found in your book, reclaiming childbirth as a rite of passage was the history of birth, which a lot of us I don't think understand that birth was not always considered such a medical event and something done to women. It was a ceremonial practice. Can you describe a little bit about that ceremonial practice? And perhaps what led to the demise of the sacredness around birth?
Unknown Speaker 0:51
Yeah, well, I would, I would argue it's still a ceremonial practice. But I'll come back to that. So Adrian Wilson kind of coined this the ceremony of birth in his writing, I think you did a PhD you did, he wrote a book about it. And it was very much about the ceremony of childbirth, in Europe, in the Middle Ages, that's kind of where he focused and I use a lot of that in my book. But it's happened globally. You know, childbirth has always been much more than, you know, a woman physically getting a baby from inside to outside. It's always been a rite of passage and a shift for the community, as well as the new person entering the community, a woman taking on a new status. And there was a really elaborate, I guess, ceremony around childbirth, that was very much the collective culture of women and was maintained by women. So it was, you know, in Europe, and pretty much across the globe, secret women's business. And it would be overseen, and that's the word that was used by the midwife who would have a very particular role. But the woman would be supported primarily by her women folk, so her sister's mother, and the other women in the community would come together during the birth to support the woman. And the midwives job was kind of a little bit more like an obstetrician, I guess, in that she would very much understand physiology and how to promote physiology, and would step in if needed, if it deviated and there was interventions needed. But these women would come together and spend, you know, hours and hours with the woman in childbirth, there were certain things that had to be done, like, depending on where the booth was taking place, in terms of, you know, closing up the doors, and, you know, plugging up the key holes, so that evil couldn't get in, there's all these other things that went on. And, you know, the lying in period was then another part of this ceremony where there was these real distinct phases. So it was quite a complicated ceremony. And really, and this is why I wrote the book, everything that happens around a woman, during her labor and birth, reinforces the cultural values, and what it is to be a woman. So that was very much around the collective culture of women and women holding other women in this transition and caring for each other. And we still have ceremony, it's just a very different ceremony, and we don't see it, because we think ceremony is something that happens in others, you know, other worlds or the countries or the times, and it's deeply ceremonial, our childbirth rites of passage in the modern context, it's just very different ceremony transmitting very different messages.
Unknown Speaker 3:26
Yeah, absolutely. Um, some of the stuff you've written. I mean, it's controversial to some I really enjoy it, because you are very good at deciphering the evidence and making it very clear for I guess, midwives, particularly consumers or women to understand some of the content on induction of labor, big babies, the perineal tear bundle recently, but also gestational diabetes, which is a big one that I hear from women. I think we perhaps the new crisis might be the perineal tear bundle. But there was a stage a few years ago that it seemed to be like, every second woman was being diagnosed with gestational diabetes. We also see as a result, I believe of this is really high induction of labor rates for low risk women. And in Queensland, that's about 43%. How much or maybe you could explain the testing and why the medical system imposes these tests on women. But how much do you think the changes to the way women are tested has impacted on this and perhaps, Why else do you think that there is, I think, an over diagnosis of gestational diabetes
Unknown Speaker 4:40
so it changed or now stay jet gestational diabetes, or the label of is the main reason for induction now in Australia, so that's, it's gone from post dates. Most women don't even get to post dates. You know, we're inducing now for primarily gestational diabetes and everything else, you know, Keep adding it, you know, hair color, height, there'll be all the, all these other things we're getting. Yeah, no, that's right. Every year, there's new new reasons to induce. And again, you know, this just reflects the underlying values and messages that we're transmitting to women, this is the ceremony of childbirth, the ceremony of childbirth now, is the underlying message is that women's bodies are really dangerous, and need to be controlled, and managed by medicine, which is quite rational, and, you know, can manage the wildness of the woman's body. And we start that very early on. And women become, by the time their birthing a baby's really reliant on external experts to to tell them about the well being of their baby. And one of the tests that we do is, you know, gestational diabetes test, which we don't actually do in every country. So in the UK, when I practice there, you only got tested, I think it's the same now, if you had risk factors, so if you had just diabetes in your family, there was a whole range of risk factors that you would then offer a test for and, and we really rarely saw gestational diabetes, it was like, if a woman was in hospital having a baby with gestational diabetes, we were all freaking out going, oh, where's the where's the policies we didn't, we were still unused to it was a massive deal. And you'd even get one of his when I worked in a hospital, you'd have kind of support midwives for high risk and support midwives. This is hilarious for low risk. And I was one of the support midwives for promoting waterbirth and physiological birth in the hospital setting. So I get called in for midwives, who were freaking out about what a birth, but you call in one of the high risk midwives to help you with gestational diabetes? Because like, What the hell do I do? Because you rarely came across it. And now it's every other woman. So what they did was, so in Australia, they screened everybody. And then they dropped the threshold for what gestational diabetes is. And they dropped it to the reason that they dropped, it was the Happo study, which looked at outcomes relating to different levels of blood glucose. And the reason that they pick the level they did was that that was the level where the baby would be. Now I'll have to read this because it's confused. It's confused, okay, the thresholds were based on the average blood glucose level value, that increased the odds of a baby being 1.75 times being large by 1.75 times. So they created this number based on the size, the potential size of the baby according to risk of the baby being big. And that threshold might reduce the size of babies, but there isn't any evidence that that threshold reduces the adverse outcomes.
Unknown Speaker 7:49
Yes. And that's one thing that is often not explained, well, it's never explained to women, and this is why they have such a hard time making proper informed decisions because things like this, I never explained to women in so much detail that whilst they might have a bigger baby doesn't mean they're going to have a bad outcome from that bigger baby.
Unknown Speaker 8:12
Know what, four kilos, I mean, when I was doing home births in Australia, pretty much every baby was over four
Unknown Speaker 8:18
is gonna say most, I've had five and most of mine have been over four.
Unknown Speaker 8:23
Yeah, get healthy. Well, women, the kind of women who are resourced enough to pay for homebirth have healthy babies, you know, and they're good size babies. And, you know, compared to the group of women are cared for in the UK, who are really socially disadvantaged, there was lots of growth restricted babies and small babies. So you know, it's about it's about the woman in a healthy well fed, a woman will generally produce a healthy, bigger baby, which is four kilos or more.
Unknown Speaker 8:50
So with these new parameters and the lowering of the testing rate, more women are being diagnosed with gestational diabetes, not necessarily the case, but how does this then change for debt Objectory of their treatment, because I often see women induce cascade of intervention, emergency cesarean.
Unknown Speaker 9:12
Yeah, and that that is what happens. So once you've been lip had the label applied of gestational diabetes, which is easy to get because the thresholds are so low, that lower than what would be expected when you're not pregnant, which is ridiculous. Lots. Yeah. So lots more women are now getting the label once you've got the label, you know, categorized as high risk and you're treated very differently set off down that track of you know, monitoring of blood sugars, you know, induction of labor offered it, which is interesting, because actually if you if you in inverted commas, control your blood sugars, if you have normal blood glucose levels, then a lot of the international guidelines say you shouldn't actually be induced because the problem isn't the label. It's abnormal blood glucose levels is is a problem. If They are too high, there is a problem, in that it alters the growth of the baby so that the baby has, you know, fatter shoulders, and the baby will possibly have hyperglycemia after birth, because it's so you know, insulin is so high, managing the high maternal blood glucose levels, that it will have a drop, because it'll still be producing high insulin, but won't be getting all of the sugar after birth. So those are kind of the things to think about the genuine high blood glucose levels in pregnancy do cause changes that can increase the chance of complications. But not necessarily every time but they increase the chance. So that's what we're trying to stop. So I would like I'd really ideally, like people to stop going on about gestational diabetes, and instead, look at healthy eating, and lifestyle for pregnant women, you know, well being, rather than, you know, saying you got to label so you have to do this. How about all women are supported, to eat well, and to maintain their health? So yeah, once they're on that trajectory, then really, it is the whole big baby induction thing, which you can't tell if there's a big baby or not by a scan, but then that's often used to add weight to the idea that the baby needs to come out, because it's all going to be really dangerous if you wait.
Unknown Speaker 11:21
Yeah, and women, like I mentioned earlier, I never explained the situation and how it came to be. And then the risk of induction, which I don't know a woman who has been diagnosed with gestational diabetes, and this is just an anecdote that then actually gone on to have a big baby or a baby, that's ended up with issues with it sugar levels after birth either. So despite these women being told of all these risks, and a lot of them are only just testing over this threshold, and they might only test once, and they can monitor their blood sugar levels for two weeks, and nothing else shows up yet they're still slapped with this label, which seemed really incorrect, but then they don't realize, I guess the risks then of that label, but then, you know, the induction 39 weeks, and that cascade of intervention that then follows and a baby that often wasn't even ready to be born. And that was born early forced out.
Unknown Speaker 12:24
Which also increases the risk of blood sugar issues with the baby if they're born too early. So yeah, but I think more than that, what we're doing is we're actually undermining the woman right at the beginning, what we're saying is that your body's not a good place for your baby to be that you're doing something that's dangerous for your baby. And you know, you need to follow our instructions in order to not be doing that and will will help save you baby from your body, you know, that what is that doing to women as they step into motherhood? Having being labeled as the danger
Unknown Speaker 12:57
Yeah, absolutely undermines their intuition, their abilities, you know, the instincts, everything and, and their confidence. And absolutely, if that's the foundation that they've had for motherhood, their self talk is that they're they're a source of not like a not a safe space for their baby. Absolutely. Whilst Do you think inductions overused in Australia? Because there's no way 43% of our healthiest, healthiest women and babies should be being induced like they are?
Unknown Speaker 13:35
Well, it's just reflects the birth culture doesn't it if you've if you've had a birth culture that's set up on the foundation, so when birth move from the ceremony of birth into hospital, women lost their female support people and midwives move from and you know, that's a whole long story, but how midwives ended up being basically taken down and then rebuilt into the, into the medical system and then midwives were now working for the medical system, not for the community, or the woman, and primarily they were employed. And that just completely shifted practice, and then shifted the messages that women were being given no, this is a this is a time when women were being put into Twilight sleeps with babies were being literally removed from their bodies while they were unconscious, during a you know, basically an operation. And that's so modern maternity system, the roots of it, were that the roots of it were women coming into a system with medicine delivering their baby midwives working for that system. And based on the premise that women's bodies are dangerous and dirty and need to be controlled, and medicine has the answer because birth is dangerous to a certain extent, you know that it's a dangerous transition for mother and baby. Some women and babies do die. So because of that, we have this system that's set in place that its intention is to eliminate all risk, but their perception of risk is that it comes from inside the woman, which sometimes it does. But actually, now the risk is coming from outside of the woman and the things that we do to the woman. That's, that's the system we're in at the moment. So induction is just an element of that, you know that we're seeing more and more induction because we consider women's bodies a dangerous place to be in for all kinds of different reasons. And because the perception of risk is about, you know, it's perceived very differently to an individual's perception of risk. So it's a generalized perception of risk. So rather than, you know, the increased chance of a hysterectomy because you've had an induction and then have a cesarean, or the increased risk of a hemorrhage, or the increased risk of childbirth trauma, we're looking at this teeny, tiny, general increased risk of stillbirth, often with gestational diabetes, there isn't an increased risk of stillbirth. Let me just say that that's not the reason. But that is proposed dates that but we're talking about less than 1% naught point naught, whatever, in populations of women who are birthing in hospital, because that's the only populations that they're studying big scale. So we're looking at these teeny, tiny risks of a catastrophic event like a stillbirth, and then putting an intervention in place that has all of these other risks that are way more likely to happen. But we don't see that as a risk, because we're saving these this naught point naught 3% of babies. And that's how the system sees risk is the safety of the safety is about the risk of death for a very, very, very small minority. So we'll apply an intervention to all in order to prevent that. And we see that in, you know, see that in all elements of medicine, don't we that we do these blanket things to a general population for a really, really tiny risk for one or two people.
Unknown Speaker 16:51
Yeah, and for those who may not have listened to previous episodes we have talked about then the link between the overuse of intervention, and particularly the high birth trauma rates. And then on the other side of that, we've got in almost every case of postnatal depression and anxiety, birth is a contributing factor yet that is never weighted at all in these things that are done to women like the physical things, the emotional aspect, is is never considered. Or I'd say in most cases, it's not considered at all.
Unknown Speaker 17:28
No, because it's about having a safely delivered. And I use that word. purposefully. Yeah.
Unknown Speaker 17:34
Yes, inverted commas, safety, because safety is the physical, not necessarily the emotional. It all, so should be worth noting that we actually haven't successfully reduced stillbirth in this country for 20 years. Despite No, I mean, you would have the data because I saw you share some things the other day that in was it a 20 year period, the induction rates probably doubled. Zairian right. And yet still birth rate? No. But yeah, that's often used for women. You know, the dead baby card is often what it's referred to by women is had the dead baby card, you know, if you don't get induced, your baby's gonna die, where no one can guarantee that, but certainly, it's not looking at the broader picture or that woman's individual circumstances, I have had very long gestation with all of my children. I managed to be induced just once, but I can see how in the system, how easily it can happen to women, because the way women are spoken to and you mentioned it earlier like that we are the source of risk for the baby.
Unknown Speaker 18:44
Yeah, yeah. And yeah, and we're not prepared to have any. It's not it's not based on individuals. So the system is based on a general risk. It's really not tailored for individual women. You know, we refer go back to the Middle Ages, with so many childbirth was centered around that woman. And yes, there was always risk in childbirth. That's why the midwife was there. I think midwives forget that we were actually there because of the risks of childbirth. But it was centered around the woman and if the midwife was answerable, not just to the woman but to the community, because she wouldn't get hired if she didn't, if she was causing trauma for every woman that she cared for. She wouldn't get hired. But now, we work in a system and our allegiances, often we feel to the system and we won't see a woman again. So we're looking after this woman for maybe a 12 hour shift, sometimes an eight hour shift. And Job is well done. If mother and baby survive tick. We don't think about well what happens when mother goes home with baby and when she's in a deep depression six months later and not interacting with the baby which impacts on the baby's mental health. Nobody's that's not a that's not factored in, because those risks don't come back to the institution. So the institutions have to report on hemorrhage rates, stillbirth, maternal death, all the big stuff The physical big stuff, they don't have to report on mental health because they don't see it. So if a woman has, you know, some major mental health issue, she'll go back into a different system, she'll go through a GP and into the mental health system. And that doesn't impact on the hospital that she gave birth in. They don't collect that.
Unknown Speaker 20:20
No. And in most situations, they don't even ask about the woman's experience. There is no, like routine birth satisfaction surveys at all in this country. I mean, there's a few pockets of it and a few studies that have been done afterwards. But there's no, I mean, if only it was collected like it is, on every other bit of physical data, we would have some, I mean, basically, the anecdote would be reflected in the data that's been collected. And I'm sure that we would see as the intervention and the continual testing that women go through as it continues to increase, that we're not improving birth satisfaction, in fact, birth trauma rates, I think will continue to rise. And then on the other side, birth
Unknown Speaker 21:08
rates. Yes, as you say, it's not actually improving the things that we're trying that the system is allegedly improving, all we're seeing is increasing interventions every year, every year, I have to when I was teaching Midwifery, every year, I get the first year students to go and get the Australian mothers and look at the data. And we talk about the stats and app. So I have to look at them every year, every year, it went jumped up a few percent every intervention, and the outcomes didn't change. So we're not and we're not measuring the outcomes of the intervention. So all we can see is this increasing intervention and no improvement. And yet, it just continues year, on year, year on.
Unknown Speaker 21:49
Yeah, and in the 90s. I believe this is there and right was around 20%. And everyone was shocked then Now, depending on what day like I mean, it's around about the same but Queensland's 36%. Why 37 And everything is trending up. There's not even like it nothing's plateauing even.
Unknown Speaker 22:08
No, no, when I worked in the UK, I worked in a high risk regional referral unit. So this was like, you know, anything that was high, that was complicated would get transferred in so our population was, you know, there was lots of low risk women as well coming into the community, but it was a referral unit for high risk. And this is Erin sexually it was 21%. Yeah, and that's a population of women who, you know, more of them would have needed this
Unknown Speaker 22:34
area. Yeah, exactly. And when medicines applied, when it should be, that's when we have the best outcomes. And it's interesting, you say that, and I know, like private midwives, their data is comparable. I mean, you've got to factor in that most women have to pay so there is a cohort that can't access it, but they do see you've got more affluent women, they do see extremely high risk women. And some of the data I see there is, you know, like, less than 10%. They're in, right.
Unknown Speaker 23:03
Yeah, because you're approaching it from a very different perspective. I looked after a woman who very clearly after the birth, had gestational diabetes hadn't been tested during during the pregnancy. But you know, afterwards, it was shattered, Shoulder Dystocia that she actually saw it at herself. Huge baby compared to last babies at 4.6 kilos. And very obviously, looking at him. He was a gestational diabetic baby, you know, that was at the top. And he was. But I didn't know because we hadn't tested for it. And she just intuitively actually managed that baby getting stuck. And then afterwards, you know, we talked about Okay, so he's looks like he's had a lot of sugar while he was in there. So let's talk about making sure that he's getting lots of colostrum and looking for signs of if his blood sugar's drop, and she managed that fine. Whereas if she'd been tested, it would have been held different.
Unknown Speaker 23:57
Or even in hospital afterwards, they would have separated the baby and then, like, just that routine separation is blows my mind as well. Can we talk about the role of midwives? I know you mentioned it earlier how it's changed. But I guess they're in this interesting position. And I know I've heard you say like, you know, just don't do it. Whereas midwives like, the whole point of a midwife was originally to serve women, but then they stuck in the system. So they kind of feel like they're having to roll out these practices. And I know, a few weeks ago, I had Nigel Leon, he's done a lot of research around the perineal tear bundle and interviewing midwives. And they were saying what this the violence around that was, they've never had it before, how much they were felt like they were forced. So they're almost in this position where they're carrying out the abuse of women. How, how do you think this is affecting the midwifery profession? And I guess, how was their role change? Because it's really significant in the way that they're delivering. I don't know if I'd always call it care, but I'll use the word care for the purpose of the interview. How has that role changed?
Unknown Speaker 25:19
mean, I think midwives and I say off the midwives are currently having a massive identity crisis, this is what I see is we actually don't know what who we are. We're kind of like teenagers not quite knowing who we are trying on different ways. And that we need to really get back to our roots. And midwives have always done interventions, that's actually when midwives were invited to birth with their capacity and abilities to know, when things were heading in the wrong direction and to intervene. And I think we need to own that. And that's why I wrote about that in my book as well. Because we think we've been so oppressed, we're oppressed group, professionally, we're trying to grasp onto this idea of what a midwife is that never existed, you often hear people saying traditional Midwifery, you know, and this, this idea that we're, we're just floating about doing nice stuff, massaging women and chanting or whatever. And play read actually never that was the gossips. The collective culture of women did that for the woman, the women who she knew and loved did all of that.
Unknown Speaker 26:25
And I think it's so valuable that you have pulled that apart in your book, that you've been very clear with that that was the role of the midwives that overseeing and they did apply intervention, but it was very different to what we're seeing now.
Unknown Speaker 26:41
Yeah, so and we still need to be able to do that, you know, family, birth, I need, the whole reason the woman's invited me to the birth is not what I'll do with the birth is what I can do. And hopefully I don't do the things I can do. You know, most of the time you don't, and you look like you're getting paid for doing nothing, because you're sat in a corner of the room. But every now and then you want to it because you're managing a hemorrhage, or you know, you're managing a complication. So most of the time, you're not doing anything. And I think we need to reclaim that aspect of our practice, which I've called the rites of protection, those interventions, because they're actually needed, sometimes during physiological birth, because physiology can turn into pathology, because natural birth is both physiological and pathological, or nature. And we also are working with women in a medical setting, who are having interventions, we need to be really good at doing the interventions that manage the complications we're causing with the interventions. So as midwives, we need to reclaim that area of our practice, I think, which I think we're trying to push away, because we want to be what we're calling traditional midwives, but not really understanding traditional midwives were always accountable to the woman and not just the woman. Midwives have always been accountable to somebody outside of their relationship with the woman, whether that's the community, the law, religion, they've always been regulated. So this is not new. It's just who we're being regulated by, and how which is medicine at the moment. You know, that's very much regulated. midwifery is medicine, because we entered in, you know, medicine pulled us in by using nursing to pull us in. And that's who we get regulated by. So we find ourselves in a situation where we're working in a medical system, but in our hearts often, that's not where we want to be, we see ourselves as midwives who yes, protecting the rights, enacting the right to protection, but wanting to be with woman, which is actually the core of midwifery. And this is what we teach at university and then the students go out enough don't see in real life, which is the core of midwifery is with women. That's what the word means. So it doesn't matter who you're regulated by, it doesn't matter where you're working. That's the essence. And if you can maintain that with a woman for that individual woman at that moment, or even on a bigger scale in research, is this with woman researchers, this research for women, and then that's midwifery. So the core resource has been there and always will be there. But it's how we interpret I think we're having a bit of an identity crisis. And I think midwives you know, in the private practice space, are seeing the rise of free birth, which, you know, yes, it is a kind of, it is a kickback in some aspects, but for some women, it's not that's just how they want to birth their babies. And they would always have done that. They didn't want a midwife or anybody else you can do things like that at their birth. So I think midwives are seeing that they're feeling threatened because they kind of will. The women don't want us and the system doesn't want us to be midwives and they're caught in the middle.
Unknown Speaker 29:41
Yeah. Yeah, it is. And then you've got then midwives that are in the system. That's a whole other range of issues that they're being like their identity. Yeah, there's several little cohorts of identity crisis, like how you talk about like, it like being that teenage aspect of who I am I and? And, yeah, it's it's an interesting space, I think during COVID, as well, when we've seen like a significant rise in free birth and also women walking away from the system, it will be interesting, whether this and I won't say it's a trend because I think there's a cohort of women who just don't know or don't have access to information. But then I think there is an increasing cohort of women that are really wanting to access information and starting to realize that often the system is duping them. So be interesting to see, you know, what, from here on in whether that cohort of women do start reclaiming childbirth?