Should home be where the birth is?

Its graphic scenes of home births aside, a new US film raises issues relevant to Ireland, where midwifery is in crisis, writes Fionola Meredith.

Ricki Lake, former talk-show host and home-birth evangelist, wants the whole world to know about the power of her "awesome vagina". Despite the chirpy, slightly icky chat-queen hyperbole, this is far from a vanity project: in her new documentary, The Business of Being Born, which she made with film-maker Abby Epstein, Lake is shown naked and giving birth in her own bathtub. The intimate footage has both shocked and fascinated the squeamish American public. After all, sweaty pink faces and heaving thighs isn't exactly the look most celebrities go for. So it's perhaps not surprising that it's the "eeuw" factor - the raw gynaecological detail - that's grabbed most attention. Salonmagazine describes Lake and Epstein's film as "a magical mystery tour of bodily fluids, sliced uteri, gloppy infants and gaping vaginas".

But Lake's delivery is an extraordinarily intense moment - and, incidentally, not at all anatomically graphic. It is just one of many moving scenes of women giving birth naturally in their own homes. No strangulated yells, rabid cursing and agonised hand-gripping here; what's striking is the serenity of the whole thing. The labouring mothers sway and squat and ululate, and it's all surprisingly calm.

As you'd expect, it's also pretty elemental. Seeing one of the mothers some months afterwards, kitted out in a prim pink sweater and her hair neatly bobbed, you'd never realise she was the same wild woman who plucked her baby from between her legs with a euphoric, orgasmic roar.

But The Business of Being Bornis more than a smug, softly lit advert for the wholesome virtues of natural birth. Described as the Inconvenient Truthof obstetrics, it holds up a very unflattering mirror to the US birth industry, making the point that medical decisions are all too often made for monetary and legal reasons, rather than for the good of mother and baby. In fact, the happy, midwife-assisted home-birthers are in an incredibly tiny minority, just 1 per cent.

Most American mothers will have a hospital delivery, lying obediently supine and labouring to an imposed schedule. The harsh, chemically induced contractions that relentlessly propel many mothers towards delivery also make it more likely that they will have to undergo an emergency caesarean section. In the US, one in every three hospital births ends in a C-section, even though the World Health Organisation recommends a rate of between 10 and 15 per cent. The surgical route has its fans, however. One mother in the film chirped: "With surgery, it's done - one, two, three."

Lake and Epstein ask whether most births should be viewed as a natural life process, or treated as a potentially catastrophic medical emergency. Has the American medical establishment convinced the vast majority of women that they don't know how to give birth?

Of course, these are not new questions. Back in the 1970s, Adrienne Rich's classic book, Of Woman Born: Motherhood as Experience and Institution, described the "alienated labour" which began when the first forceps-wielding obstetricians took over the birth process from the midwives, with their intuitive, hands-on knowledge.

But Abby Epstein believes the situation is worse than ever. "At least in the past women had more choices, but now the pendulum has swung so grotesquely far that we have lost sight of what childbirth actually is," she says.

Isn't there a risk, though, that women will feel preached at by the film, made to feel almost guilty for having a medically assisted birth in hospital?

"That's the last thing we want, for people to feel bullied or pressured," Epstein says. "We just want women to have the choices that aren't there for them at the moment."

WHILE MIDWIVES AREa rare breed in the States, they are a familiar part of the birth process in Ireland and the UK. Yet there's a fear among health workers and maternity campaigners here that we could be heading down a similar road to the American model. Marguerite Hannan, who works for the Homebirth Association of Ireland, says that the same process of medicalisation is underway all over the world.

Breda Kerans, of the Association of Improvements in Maternity Services Ireland (Aims), recently arranged a screening of Epstein and Lake's film in Galway. She says that with the caesarean section rate in Ireland standing at 30 per cent, there is no room for complacency.

"It's a worrying trend, and it's driven by fear of litigation," she says. "If you aren't progressing quickly enough along the delivery timelines, they will speed you up. Yes, hospitals are there for a good reason, and that's necessary. But we shouldn't treat people as though they are ill before they actually are - it's like removing everybody's appendix in case they get appendicitis".

It's a similar story in the North, where the caesarean rate stands at between 24 and 26 per cent, rising to 30 per cent in two of the largest maternity units in Northern Ireland. Dr Niamh McCabe, consultant obstetrician at Lagan Valley Hospital in Co Antrim, is concerned.

"We should be encouraging normal birth. But society is getting more medicalised," she says. "People's confidence in their ability to look after themselves seems to be faltering".

Yet is home birth the answer to an increasingly interventionist birth experience? Despite the fact that the norm of hospital births is a relatively recent phenomenon, deep-rooted concerns about safety mean that many women, even those ambivalent about hospital deliveries, choose the well-trodden path to the maternity unit.

"Actually, study after study has shown that home birth is safer than hospital birth," insists Marguerite Hannan. "Midwives don't just rely on reading monitors, they read the whole woman, for hours and hours on end. They build up a relationship with her. So if something takes a turn in labour, it's not an emergency - the midwife is prepared."

Hannan says that interest in home birth is growing in Ireland, but that there are not enough independent or domiciliary midwives to service the demand. "There are 400 planned home births a year. That would increase tenfold if we had the midwives."

AS IT STANDS, there are only 20 independent midwives in the country. And soon it will become even harder to have a midwife-attended home birth in Ireland. Last year, independent midwives were informed that the Irish Nurses Organisation (INO) planned to withdraw indemnity insurance for independent midwives. No solution to the problem has been found, and with the final deadline of March 31st approaching, midwives and their clients are apprehensive about the future.

Krysia Lynch, of the Homebirth Assocation of Ireland, says: "Women who are already booked in with an independent midwife are now not sure if they will receive care. Midwives simply don't know what to do - they have a duty of care to their clients, but how can they provide care without insurance? My concern is that someone who had a previous horrendous experience in hospital, and who had planned a home birth, might be tempted to go ahead at home with no support. We would never advocate that, but it could happen."

Much of the hope for the future of midwifery lies with the new generation of students coming through college. Nicole Schlogel, a third-year midwifery student at Queen's University Belfast, and a mother of one, says that she always knew she wanted to be a midwife. But it was her own birth experience, in which there were a number of complications, that crystallised her determination to qualify and practise.

Schlogel, who is helping to organise a special screening of The Business of Being Bornin Belfast, is currently fundraising for a trip to The Farm, in Summertown, Tennessee, the home and clinic of Ina May Gaskin, featured in Lake and Epstein's film and often described as "the mother of authentic midwifery".

But Krysia Lynch fears that the longer the situation goes on without a resolution of the insurance problem in Ireland, the more midwives will leave independent practice, and their precious skills will be lost forever. "In the UK, it's different - midwifery is alive and kicking," she says. "But Ireland is at a crossroads. Either we'll go down the route of women being strapped down and told their body is ineffectual, or we will have a revolution in maternity care, a great revival of maternity skills. I hope it's the latter."

Ricki Lake and Abby Epstein believe that they have made an inspirational film that shows natural childbirth as the everyday miracle - and profoundly life-changing experience - that it is. Whether they can convince the pain-averse prospective mothers who, in the words of one consultant in the film, "think that having an elective caesarean section is like having a Prada bag" remains to be seen.

www.thebusinessofbeingborn.com