Where is my midwife?*

главный редактор журнала "Домашний ребенок" и президент МОО "МАМА"
homebirth in Russia

About the author
Katerina Perkhova, “Domashniy Rebenok” magazine editor-in-chief and president of Inter-regional Organisation "MAMA"
Translation: Alina McCreery


After the placement of this article, my access to the Internet community dedicated to unassisted birth was denied on charges of publishing false information about the number of tragedies in delivery without obstetric help. To my sorrow, both of these cases are real. Inter-regional Organisation “MAMA” received formal requests to this effect.

It is enough to see a few reviews about hospital births in Russia to become worried and start to look for an alternative. But is there any in the post-Soviet arena**? - Not yet. 

1. Why?
Maternity hospital doctors, who meet only tragic home birth cases, are dead right to call  it “Russian roulette”.

No profession. At the present, there is not a single official school in Russia capable of training independent midwifes (to work outside hospitals) or awarding CPM or CNM (Certified Professional Midwife / Certified Nurse-Midwife), internationally recognised certificates  since state medical colleges teach how to assist in childbirth mostly in a hospital setting.
 
No legislation. According to existing legislation, a midwife, however much she might desire it, cannot obtain a license to practice out of hospital. There is no any special law or arrangement to control this type of activity.

No statistics. There are neither general nor detailed official statistics of deliveries out of hospital in Russia. (References on the Internet are sporadic and often anonymous. There is neither a register of midwives who have been trained and are experienced nor is there a commonly agreed code of practice).
 
Thus in making a decision to give birth at home one needs to be prepared for the possibility that some midwives may not be qualified enough (or even not a midwife at all), may use dangerous and/or unauthorised medicine. And she, most likely, will not be able to go with you to maternity hospital in the event of an emergency. Should a tragedy happen during birth, she may be prosecuted, and parents may have to endure questions from criminal investigators and social service inspectors.

2. National midwives and midhusbands.
The Russian movement “For natural birth” appeared at the end of the 70s in the last century when parents consciously started to prepare for sea births and births in experimental water birth centres  as a way of defending themselves and their children against staff aggression and “prison rules” in the country's maternity hospitals. The number of such families has grown steadily. They have formed clubs. This is how the first national midwives appeared, having metamorphosed over the last  40 years from parents of many children into experienced specialists in physiological birth, many of whom have attained college and university medical degrees. They prepare future parents for birth very well and some of them supervise in hospital births. 
Nevertheless, according to current legislation they can not get an official license to practice out of hospital.
But for a lack of a general code of practice and lacking official or public regulation, the way they may approach their work is extremely different: some suppose religion and philosophy to predominate over midwifery, others have an unjustified 'medical' approach (which is more likely to end up with dangerous complications in the case of non-hospital birth) while still others prepare only for unassisted births (without midwife). Both a system of post-birth care and pediatric or neonatological check-up of a newborn baby are absent. There is no register of statistical data.

3. Unassisted birth.
We will not take into account the issues of personal freedom, female strength and natural wisdom. When mum and dad give birth as a couple, this is a special, inexpressible, absolutely intimate experience. You may read numerous inspiring stories about unassisted births in Internet communities dedicated to this question. Moreover, a RF Federal law issued on 21st of November, 2011 “On the principles of safeguarding health of citizens of the Russian Federation” grants the right to refuse any medical interference. The Constitution of RF guarantees freedom of choice. 
Nevertheless, if our priority is a healthy and happy mother and child rather than home birth at any cost, it would be beneficial to discuss safety and responsibility issues as well as the reasons that bring more and more parents to unassisted birth without midwife assistance.

Safety.
If it is possible to uncover some unofficial statistics of planed home births that have been collected by midwives, yet the results of unassisted births are absolutely unknown. So far only two contradictory surveys have been found:
1) Kazan city scientists compared the results of home birth cases without midwife assistance with hospital birth ones and discovered the following: “When a woman in childbirth is deprived of midwife supervision, worsening does not occur (which would be logically expected), rather there is an improvement for both mother and foetus. There are birth result improvements in all points, except one: there is a rise in average blood loss,although this is not higher than the norm. <...> We clearly understand that improvement in home birth results is possible only during uncomplicated childbirth. It is possible that following a comparison of a greater scope of data there would be a less favorable impression, however, the current analysis allows us to affirm that overuse of manual means and instruments as used by medical midwives is more likely to cause great harm than non-intervention in the millennial-old natural birth process.”

2) A report about perinatal and maternity mortality in one of the religious communities of Indiana whose members refuse any medical help and give birth with no assistance reveals the following data: “48 antenatal deaths to 1000 live births compared to 18 cases in 1000 childbirths for all other state of Indiana inhabitants. The estimated instance of mother mortality <...> comprises 872 deaths in 100 000 births compare to 9 in 100 000 for other state of Indiana inhabitants.”

When world charity organizations struggle with a shortage of midwifes in developing countries where 1 in 39 women risk dying during the pregnancy or childbirth (according to African data where most deliveries occur without midwife assistance)can we really consider unassisted birth in Russia safe?

Over the last months we have received two queries here in “MAMA” and both are related to tragedies that have happened in unassisted births.

Despite the existence of unassisted birth internet communities, it is difficult to obtain valid statistics on the safety of unsupervised births. This is covered by Ricks Frieze in her doctoral thesis on the phenomenon of unassisted births in North America, “With unassisted birth, there is a paradoxical withdrawal from conventional socialinteractions that surround pregnancy and birth and an immersion in alternative virtualcommunities in which unassisted birth is seen as a normal, reasonable choice. Women oftenwithhold their birth plans from family and friends, fearing disapproval and negativity. Some also worry about governmental interference because of their alternative choices, so they toochoose not to reveal their plans. In order to make up for the social isolation that UC oftenbrings, they selectively enter into intentional communities that support unassisted birth. Thedifference, though, is that participation in these virtual communities is anonymous andwithout accountability. Women can join or leave online groups as they please, easilyvanishing into the ether of the internet without a trace when they no longer desire toparticipate.”

Responsibility.
Needless to say that any means of giving birth, be it at home, in the sea or in a maternity hospital, is the responsibility of parents. How did they prepare themselves? How did they choose the place and supervisors? How did they ensure safety measures? Giving birth to children is a natural physiological process with the majority of births occurring successfully.

Yet in the event of tragedy the question of “who is to blame?” becomes paramount.
What will happen next depends on where and with whose support the birth took place.

If in a maternity hospital, then the outcome depends on the results of the medicolegal investigation, the mood of the parents and the professionalism of the hospital staff. In this case there is no legal reason to blame the parents.

Home births: if the birth was supervised by a midwife or doctor, then at present the specialist will more likely be tried under article 235 of the Russian Federation Criminal Code for, “illegal practice of private medical activities leading to death of a person through negligence”. Here, parents are usually come out as victims.

But if a tragedy occurs with unassisted births, then it is up to the parents to prove that they “did not plan to kill their own child”. (It was precisely with this case that two families became entangled when they turned to the organization “MAMA”). If there are already children in the family, then a situation of this kind carries further possible consequences in the form of limited or deprivation of parental rights in relation to older children.

Reasons.
A survey was conducted in one of the unassisted birth communities with the main reasons for parents choosing unsupervised births being:
1) “The desire for the intimate atmosphere of giving birth”
2) “We don't have midwives in our acquaintance / there aren't any midwives in our town” 
Two more reasons may  be added to these two that I found out about from personal contact with mothers who gave birth unassisted:
3) “I feel uncomfortable with Guru spiritual-midwifery and I just want assistance in giving birth and not to have my mind manipulated forcing me to go to communion otherwise “the birth won't go off” or to chant mantras from morning to night otherwise my “consciousness won't be cleansed by the time of birth and it will all end in tears”. And if something goes wrong with the birth, they'll just say to me, “What God gives, He may likewise takes away”?...”
4) “I haven't got the money to pay for a maternity hospital birth or for private midwives in another country.”
 
Thus we have two profound problems: a lack of licensing for private midwives and a professional crisis within the midwifing community itself.

What can be done?
Legalise the practice of midwifery providing assistance in home births.

The organisation “MAMA” has several ideas and projects which urgently require your support (and we also welcome new suggestions and comments):

1) Experimental project: “Safe home births” in which it is necessary to organise:
  • official support and co-operation with medical organisations
  • training of Russian midwives on international programmes to receive CPM and CNM certificates
  • professional practice for midwives under the leadership of experienced professionals
  • statistical research in the framework of the experiment 
2) An independent investigation of maternity hospitals (an enquiry into putting the requirements of a Ministry of Health and Social Development Methodological letter of 13th July, 2011 into practice) and the establishment of a Parents' premium for midwives and maternity hospital doctors for supporting natural and gentle births as far as possible (we shall award and create a rating of maternity hospitals which in deed, not only in words or as a paid service, support all kinds of natural family births, breast feeding and bringing mother and child together). 

Please,
if you are prepared to participate in these projects, contact us.
If you have the opportunity,
please support the efforts of IRO “MAMA”!

PS
We should like to inform you once again not to take anything at face value and to ask both maternity hospital doctors and those assisting you in a home birth as many “uncomfortable questions” as you can. Critical thinking and a conscious approach are of paramount importance. A good specialist would never interfere with your independence, but may also save your life as well as the life of your child. 

* the idea for the slogan "Where is my midwife?" came from the international movement supporting midwifes wheresmymidwife.org
** at the present it is possible to become a licensed midwife to assist in home birth in the Netherlands, Great Britain, Germany, Denmark, USA and other countries: http://www.domrebenok.ru/blog/karta-mira-gde-mozhno-rodit-estestvenno/ 
*** According to a UNFPA report, each year in 58 developing countries it would be possible to avoid up to 3.6 million deaths if the number of midwives were to be increased by 2015. Worldwide, there is a shortfall of 350 000 midwives. The report mentions that if midwives were to assist in births and were to send the most serious cases to medical establishments, it would be possible to prevent up to 90 % of maternal deaths ... 



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