My guide to a positive birth experience

Here are some tips for preparing for a positive (natural) birth experience. However, they still apply in situations where medical intervention becomes necessary.


It can basically be broken down to two main aspects:

1. Preparing oneself for the birth; physical preparation (nutrition, exercise, body work), spiritual (prayer and meditation) and psychological (mental pain management techniques), as well as becoming informed of the birthing process and about common medical interventions (including making a birth plan).
2. Choosing appropriate caregivers and supportive birth partners, who will help maintain physical and psychological health during pregnancy and create a calm, supportive birthing environment

A third aspect, I suppose, is implementing this advice when you actually go into labour. 

There is a lot of good information about these topics, so I won't put everything down.  Below are just a few things that may not be commonly known.

1. Preparation

Health and well-being

• Pre-conception health is important - one reason is infections existing at the time of conception can reach the placenta and be more likely to cause premature labour.
  More: http://mobile.nytimes.com/2014/05/22/health/study-sees-bigger-role-for-placenta-in-newborns-health.html?smid=fb-share&_r=1&referrer
• More on pre-conception diet: http://www.bbc.com/news/magazine-34222452
• Nutrition during pregnancy - the Brewer diet is often recommended in the USA, but there has been some criticism of it as not being evidence-based.  The more I learn about a vegan diet, the more I realize that it is most likely the healthiest way for us to live, even (maybe especially?) during pregnancy. There are some people who claim a plant-based diet helped them conceive after years of TTC. However, it is very important to make sure all vitamin requirements are met, such as protein, iron, calcium and especially vitamin B12. Here are some resources to consider in regards to a vegan diet in pregnancy or in general:
• Vegan Pregnancy: Preventing Birth Defects
• nutritionfacts.org
• Forks over Knives (film)
• Thriving on a Plant-based diet http://doctorklaper.com/webinars/thriving-on-a-plant-based-diet/
• Dr. Klapper's take on dairy - http://doctorklaper.com/answers/answers11/
• On a similar topic, American midwife Nancy Wainer reccommends to her clients to avoid dairy and also sugar, as she believes these tend to contribute to larger than optimal babies which are a bit harder to birth. http://www.birthful.com/podcastvbac/ The reason for the dairy being problematic could be to do with Dr. Klapper's proposal that dairy is growth inducing.  The presence of these growth factors are actually quite harmful to our health, he proposes.
• Exercise - there was a study about how much exercise a mother did during pregnancy: babies whose mothers exercised had better health at birth. It also helps you maintain a healthy weight, as being overweight increases your risk of health complications. http://fitness.org.au/articles/health-lifestyle/more-activity-during-pregnancy-better-mood-and-less-worries/2/812/184
• Exercises to help you have enough strength to care for the baby are also helpful - your arms will get a lot more work than they are used to when you have to lift and rock the baby!  It's good to be ready for that!

Exercises and treatments for positioning in pregnancy and birth

• Fetal positioning exercises are helpful in positioning the baby for an easier birth. For example, to avoid a breech presentation. You can start early in the pregnancy. Part of it is just how you use your body every day, such as avoiding standing or sitting for too long, walking and stretching regularly etc.  Another part of it is specific exercises that release muscular tension in muscles supporting the uterus that may be unevenly tense leading to the baby not having enough room to move into an optimal position for birth.
  See http://spinningbabies.com/ and http://spinningbabies.com/product/spinning-babies-parent-class/
• This is also a great video explanation: https://www.youtube.com/watch?v=qsV70xXivH8
• Exercises for core strength are important to improve the baby's position to avoid a difficult labour, avoid diastisis recti and gynecological problems like prolapsed uterus in the future. Wearing a support belt can also help.
  See http://midwifeatyourdoorstep.com/articles/optimalfetalpositioning.html
• Another perspective on the pelvic floor and why squats might be better - http://breakingmuscle.com/womens-fitness/stop-doing-kegels-real-pelvic-floor-advice-for-women-and-men
• There are numerous exercises and positions that can be helpful in labour that not only aid in the baby's positioning and descent, but also in the release of painkilling hormones.  For example, learning forward, swaying the hips and using a birthing ball, plus the spinning babies labour exercises, especially "The Fantastic Four". http://spinningbabies.com/learn-more/techniques/the-fantastic-four/
• Chiropractic care (especially the Webster technique), osteopathic care or other forms of bodywork can be options - if your pelvis is misaligned or the muscles that support the uterus are unevenly tense, birth can be more difficult because it's harder for the baby to get into an optimal position. Spinning babies explains very well why this is the case.

Emotional readiness for birth

• Previous trauma, perhaps because of sexual abuse or traumatic sexual experiences can affect birth by making the mother less able to release and relax in labour, other emotional issues and stress can be barriers to a good birth experience, so it's worth working through these.

Psychological preparation for birth

• Many women like the idea of going drug free, but when the time comes, they are unprepared for how to handle the sensations.  In addition to things like rocking the hips, using a birthing ball, being upright and especially leaning forward, mental and breathing exercises can really help. 
• Hypnobirthing/natal hypnotherapy, "Calmbirth", as well as mindful meditation are all mental preparation tools that help manage stress in pregnancy as well as providing wonderful mental coping strategies.  During my first pregnancy, I ordered myself a Hypnobabies self-study course. Here is another good video about hypnobirthing. Some women achieve pain-free labour using these techniques. I personally didn't have that experience, but I still found the preparation helpful in getting through my 36 hour labour. There were some aspects to that philosophy which I now find lacking.  For my second birth, I prefered to use mindful meditation.  The book "Mindful Birthing" by Nancy Bardacke was quite helpful.  You can listen to it here.
• I also really like the Bradley method, especially the deep breathing. Oxygen helps reduce lactic acid build-up, which is part of what causes pain - https://www.youtube.com/watch?v=I5HJ83xXQvM
• Lamaze breathing is another option
• Read POSITIVE birth stories that help create a positive mental picture of what birth can be! For example, http://birthwithoutfearblog.com/

Spiritual Preparation

• Connected to psychological and emotional of course, but spiritually preparing oneself through prayer and meditation is very important in helping to prepare ourselves for whatever happens, and also in overcoming fear.  Some people talk about birth as being a spiritual experience.  I think it is! Part of that can be learning to accept whatever happens and surrender to the power of the experience.  This is a bit different to the hypnobirthing perspective which states that birth shouldn't be painful.  Perhaps it can involve pain, but if we surrender and relax and use it as an occasion for spiritual growth, it is bearable and a very positive experience.

Become informed about birth physiology

It's really helpful to understand the beauty of how our bodies were designed to function and how to support the body in reaching its biological potential, thus reaping the benefits of a physiological labour, birth and post-partum.

• Phsyiology of birth, hormones: http://sarahbuckley.com/pain-in-labour-your-hormones-are-your-helpers
• The human biome, birth and the health of the baby: http://midwifethinking.com/2014/01/15/the-human-microbiome-considerations-for-pregnancy-birth-and-early-mothering/
• Other forms of natural pain relief - water birth, music, movement etc.
• Active birth - http://www.bellybelly.com.au/birth/active-birth#.U5tTr_mSwRc
• Environment for birth by Michel Odent - https://www.youtube.com/watch?v=xk0QMq_agOo
• Anything by Ina May Gaskin!
• Here are some other general sites that could be helpful:
  Science and Sensibility
  Positive birth movement
  improvingbirth.org
  bellybelly.com.au
  http://homebirthersandhopefuls.com
• evidence based birth
• birthful podcast

Become informed about birth and newborn interventions

• Why we shouldn't just go with the flow - http://birthtraumatruths.wordpress.com/2012/03/26/the-pitfalls-of-going-with-the-flow-in-birth/
• Medicalization of birth in hospitals- https://www.birthinternational.com/articles/birth/18-fish-cant-see-water
• The Business of Being Born (film) discusses medicalization of birth and explores homebirth as an alternative.
• Learn about common interventions, such as induction, augmentation, episiotomy, forceps, ventouse as well as pain medications, such as epidural, and their effects.  In a normal labour, these are rarely needed.  For alternative perspectives on birth practices, see - 
• AIMS website
• Neighbourhood midwife: https://www.youtube.com/channel/UCraC14Kv89T9POXdkj8NMrw
• Midwife thinking (love this one!!): midwifethinking.com
• Once again, remember that when it comes to interventions, you have a right to informed consent.  Opinions vary about what interventions are needed and new information is coming up all the time about what is best.  One intervention to avoid is induction.  Here is another good article by Sarah Wickam. Stay strong in those last days! And remember that in the past, a 10 month pregnancy was not so unusual!
• Investigate newborn practices: http://blindedbythelightt.blogspot.com/2012/10/newborn-procedures-to-reconsider.html

2. Choice of Caregivers and Birth Setting

Caregivers

If at all possible, my personal preference for a caregiver for pregnancy, birth and the postpartum period is midwifery care.  Midwives are trained to support normal birth and do a lot to make that possible, including providing information about nutrition and health, providing support in labour and parenting and breastfeeding support afterwards. Research shows that midwifery care, especially when it is continued from the duration of pregnancy results in a much reduced level of intervention compared to obstetric care, even when looking at women of the same risk factor levels. Why is this the case? Well, obstetricians are experts in managing all the complications that can arise. In their training, they rarely see a normal, uncomplicated and unmedicated delivery.  They see all the risky cases where medication, monitoring and/or surgery is needed.  When they see a healthy women having a normal labour, they can tend to see signs of complications, when in fact there is nothing wrong.  They are just so used to intervening that they are uncomfortable sitting back at letting nature sit in the driver's seat.

This article explains quite well what the differences are between an obstetrician-gynecologist and a midwife.  This youtube talk is also very interesting.

Having said that, it does matter what kind of experience the midwife has had.  An independent midwife who has a lot of experience in homebirth is more likely to have skills and knowledge that will help avoid unnecessary interventions than one who has mainly worked in a high-risk hospital setting, for example. It's important to talk to your midwife about how she feels about things like prolonged pregnancy (going past your due date), meconium staining, waterbirth, delayed cord clamping, nuchal cord and so forth (midwifethinking.com explains how many of these things are not as scary as they are made out to be).

Where you have the birth also matters - this article explains the options quite well.

If you're planning a hospital birth, it's especially important to be informed about medical interventions in birth, and when they are needed as well as when they are not necessary.  A birth plan can be helpful in this regard.  A birth plan is not just a list of what procedures and medicines you want and don't want.  It recognises that sometimes there are deviations from the norm, and so a birth plan has a plan B and maybe a C and D.  It answers the question "How can I keep things as optimal for my baby's health and my birth experience if I this or that happens...".

In any setting, but especially in hospital, a doula can be helpful in advising you about medical interventions, advocating for your wishes and providing physical and emotional support.

Birth environment and setting

It should be noted that birth outcomes are not just about the health of the mother when she walks into the hospital.  And it's not just the interventions she endures, either (though this is very significant).  It is significantly linked to how the mother is feeling.  Her emotions (such as feeling in control and safe in her environment versus scared and powerless) can help or hinder the release of birthing hormones and it is these that ensure safety! Not many obstetricians acknowledge this.  They think they can manage things when they go wrong, but what about preventing things from going wrong in the first place?! Allowing the hormones to function properly, through meeting the physiological needs of a labouring women can do a lot to doing this. This includes the things I've mentioned, plus a darkly lit, warm, quiet and private space.  These things also make the 'pain' of childbirth less 'painful'.

The home environment provides all of these conditions - a sense of familiarity, control over the physical space and how others interact with you in your own home, privacy and freedom of movement, freedom to access natural comfort measures, and a much reduced likelihood of unnecessary intervention. Plus, when intervention is needed, most western countries have the facilities to make a quick hospital transfer smooth and successful. I feel that choosing home birth is about giving yourself the best chance of a successful physiological birth.  So, given a situation where there are no pressing medical concerns, I would never ever choose a hospital birth, if I had the choice. I know that not many women don't have that choice, so then it is about optimising the hospital experience so that it supports normal physiology.

This talk explains the advantages of homebirth and you can read more about homebirth here.

Rallying Support

Finally, it's important who you invite into your birthing space and their attitudes towards natural labour.  Not just the care provider and possibly a doula, but also family members! Rhea Dempsey in her book "Birth with Confidence" emphasizes that a birth support person should be strong for the mother and not overly sympathetic.  She tells the story of an athlete preparing to do a solo swim across a sea. She carefully selected a small group of people who would be in the small boat that would pull along the shark cage she would be swimming in.  Their role was to watch out for hazards, cheer her on and possibly pull her out if she had an accident.  She would have to swim throughout the night and day for a long period and she knew that she needed to keep up her morale, because there would be times when the loneliness, the cold, the fatigue and painful muscles would get too much and she would beg to be pulled out.  She knew that if her own mother was on that support boat, she would not have the strength to watch her daughter begging to be taken out and refuse to do that.  The swimmer didn't need people on the boat like that.  She didn't need rescuing when all that was wrong was a lack of confidence, but rather she needed people who could be strong for her, to rally her on and show that she believed in her strength. In every labour, there are times when the sensations get very intense.  We don't need the siren call of the epidural.  We need someone to tell us "you're doing a great job, even though you don't feel like it, you are so strong and you are going to birth this baby so well!".

Conclusion

To conclude, both of these aspects of personal preparation and supportive care are important. In stories I hear about birth, it sadly happens too often that a woman is well-prepared for birth but her experience is made so much harder by caregivers who are uninformed about best-practice and are too keen on intervening.  Sometimes it's not possible to avoid this, but in some cases, women pay extra to go to a private hospital and end up receiving unnecessary interventions because their caregivers are just more comfortable with medicalized birth.  On the other hand, a woman could have awesome caregivers, but still have a less than ideal experience if she has preventable health conditions or makes decisions based on unnecessary fear or lack of preparation.  However, I tend to think that the choice of caregivers could perhaps be more important than preparation.  If a women is minimally prepared, but has a great midwife whom she trusts, her midwife can really help her navigate the common pitfalls she could encounter.  And, of course, in the end, birth is not in our control and we shouldn't feel guilty if things don't go to plan or if we were unaware of something we later realized was important.  We do the best we can under the circumstances and in every case, we learn and grow!

Maternity Care in Bosnia

In the past few months I've learnt a lot about the maternity system here in Bosnia.  This is because I met some Bosnian ladies who are interested in natural birth and these women shared with me their birth stories as well as their knowledge about the system here.  I have also gone around asking quite a few ladies I meet in everyday life about how they felt about their births.  I would have loved to know so much of this stuff when I was pregnant, so that's why I'm sharing it now.  I guess it should be taken with a grain of salt, since it's based on second hand information in some cases.

Midwifery in Bosnia
Midwives aren't very well thought of in Bosnia. The word used to describe them, "babica" also means "grandmother", so it's not surprising that people associate homebirth with poor families who can't afford to go to hospital and just get a 'grandmother' to help.  Such midwives quite possibly still exist in the countryside, but in the city, it seems that midwives only practice in hospitals. There is a course available for training midwives, but it is only a highschool degree from the medical highschool in Jazero (maybe there are others in other parts of the country). Beyond this highschool qualification, there are some short courses offered by the Centar Fenix and that is about it!  I spoke to a girl who I know who goes to the medical highschool.  She will become a midwife only if she doesn't fulfill her dream of becoming a footballer!  None of her friends want to be midwives either if they can help it.  It seems more like a low-level job that they will do if they can't find anything else.  (As a side-note, I asked her if she had witnessed a birth and she said, not yet, but she had seen an abortion. Hmmm...) Not surprisingly, those that do decide to work as a midwife finish their training in the hospital by watching doctors (obstetricians) practice and being instructed by them.  They end up being like obstetric assistants who are probably very out of touch with what it means to a woman to have a baby (especially when starting out fresh from highschool).

Apparently, the training for midwives before the war was more complete and so the older generation of midwives are more skilled, for example with breech birth and twins. Despite this, even they don't have much autonomy within normal hospitals.  They supervise the labor but aren't able to administer medications or perform medical procedures and must call in the doctor (who works in shifts) for the birth.  Apparently, there were some midwife led birthing units in the countryside, but these have been progressively closed in accordance with a policy of closing smaller maternity hospitals to redirect women to larger, more "equipped" hospitals in the so-called interest of safety. I say "so-called" because, actually, by sending women to centralized units and closing down local ones, you are making it more likely that women may give birth on the way to the hospital, which is probably the least safe option.

Birthing Options
The only real option women have is to go to their local public maternity hospital.  There are no private hospitals in the capital, but I've heard there is one in Pale (Republika Srpska) and also one other private hospital in Banja Luka (also Republika Srpska).  Homebirth is commonly thought to be illegal.  It is probably not actually illegal, maybe just a grey area, but perhaps there was a push to discourage it at some point because it seems like it used to be common but isn't anymore.  It is now considered an uncultured thing only peasants would do.  This combined with the minimal training of midwives and obstetricians' general preference for hospitals and that leaves you with a situation of no homebirths. In any case, no one I know has found a health care practitioner based in Bosnia who will assist them in a homebirth.  It may be possible to bring in a midwife from another country, but it would be difficult to get back-up from the hospital. Birthing centres do not exist either.  Apparently midwife-led maternity units used to exist. Maybe a couple still do, but I'm not sure how they would compare to what I would think of as a birth centre. I think they would really be more like a normal hospital, only without obstetric back-up.

Prenatal Care
Pregnancy is rather medicalized.  There are only two options for prenatal care - seeing the doctors in the public system (in a clinic known as Dom Zdravlije or the hospital) or seeing a private obstetrician-gynecologist.  Women, even those in the public sector, are advised to have an ultrasound at least once a month for the entire pregnancy.  Doctors do not palpate the belly to examine the baby's position or growth, they rely exclusively on ultrasounds.  They have short appointments with their patients where there isn't much time to talk about diet or lifestyle, but they do quite a number of tests and examinations.  Some women are given additional medications which seem excessive to me, such as hormonal medications to "keep" the pregnancy or prevent contractions. At 36 weeks, the woman books into the hospital and starts having weekly examinations, including CTG, ultrasounds, vaginal examinations and possibly more. If a women reaches her due date, she is sometimes encouraged to have an induction immediately or if she prefers to wait, more frequent (even daily) monitoring is done and in a friend's case, amnioscopies were ordered frequently to check for meconium staining. The last is quite an invasive and risky procedure that has little benefit in helping the outcome. This isn't all bad by any means, some of these things can be quite useful, but what I'm noting is lack of the continuity of care midwifery model as well as excessive use of technology and tests.

Hospital Birth Practices
Based on listening to the birth stories from a few women, it appears to me that doctors in Bosnia prefer to "actively manage" labor and birth.  That is, there is a specified time-frame within which a woman must dilate and also push out the baby before which time they will intervene to speed things along.  In accordance with this view, and other beliefs (many of which are not evidence- based), the following interventions are common:

• routine shave and enema upon admission (expectation that shave should be done before going to hospital)
• frequent artificial breaking of waters
• frequent chemical augmentation through artificial oxytocin drip
• artificial rupture of membranes
• pushing lying on back (lithomy position) on birthing table
• panic if baby is not pushed out in a few pushes
• use of fundal pressure to increase speed of birthing (doctor or nurse pushes on the top of the uterus to increase the force of pushing putting extra pressure on the vaginal wall muscles and increasing the likelihood of perineal and pelvic floor damage)
• routine use of episiotomy for first time mothers (and frequently otherwise)
• immediate cord clamping
• a quick cuddle and picture with mum and then off to the nursery baby goes to be weighed, measured, vaccinated, given vitamin K injection, quite possibly fed formula or sugar water before being returned.
• actively managed delivery of the placenta - use of injection to initiate contractions and control bleeding
• mum gets her episitomy sewn up and rests while baby has his or her examinations with strangers
• mum gets to breastfeed her baby a few hours after birth (maybe 4 or more). 
• The baby is quite possibly full of formula when it comes time to be nursed.  (The national hospital, Abdullah Nakas hospital is supposed to be a baby friendly hospital, but according to one woman who had an insider's view of it, she found that the baby friendly standards were not being adhered to as they should be.)

Also, it seems like there was an insistence on laboring in bed, in some hospitals through use of CTG monitor (meaning you are strapped to a monitor) and drips, in others simply because they want patients to be in bed.
Water birth is supposedly available in the national hospital, but few (if any) women have been actually allowed to give birth in water.  Probably because of a general mistrust of water birth and their belief in the need for episiotomy. The C-section rate is about as high as in western countries - approaching 30%. Doctors work on shifts and you can't know who will be on shift when you go into labor, but I have heard of women bribing doctors to give them a non-medically necessary C-section when their preferred doctor is on shift. This is probably because of the (in my opinion) terrible vaginal birth option that hospitals offer as the only alternative.  By the way, C-sections are usually done under general anesthesia, rather than epidural.  I also heard of one woman who was offered an induction (as a favor) when her doctor was on shift so that she could birth with her doctor.  Further, although some of the older midwives and doctors have skills in things like breech birth, the newer doctors are trained to opt more frequently for C-sections, so I hear often about women having c-sections for 'big babies', twins, VBAC and breech.  In terms of breech, apparently only one doctor offers external version (to externally flip a breech baby).

It goes without saying that in such a medicalized environment, doctors would likely be incredibly "cautious" when it comes to premature rupture of membranes and presence of even lightly stained meconium in waters.

There are probably exceptions to the list of interventions I have given.  Maybe some doctors are more liberal in allowing different positions for labor or birth and so forth. I have read one positive birth story in which a woman who was having her second child did not have an episiotomy and the doctor massaged her perineam instead.  I'd tend to think that that is the exception rather than the rule, sadly.

Conditions in Hospitals
Generally only one person can be with the birthing woman.  When I first wrote this article, there was one doula in  Sarajevo, apparently. She could only attend births by pretending to be a cousin but eventually was recognized and not allowed to come anymore.  Since then, in 2016, a number of women trained to be Doulas with Dona International - the first training session of this kind in Bosia-Herzegovina.  It remains to be seen whether they will be allowed into hospitals.  Fathers are allowed under certain circumstances I'm not so clear about.  Perhaps you have to be in a special room because generally there aren't single rooms.  The national hospital has rooms for two people (though it's not so busy, so often the room is to oneself), and Jazero hospital has rooms for four. So, not so sure about the rules for participation of men, but I've heard a few stories which make it seem like men are not welcomed as they should be.

The large hospitals are quite well equipped.  I think that they probably okay at managing genuinely complicated births... but then again, there was one comment from a friend that indicated that some high tech equipment that was donated is just sitting there not being used because staff don't know how to use it.

Finally, and I think this is the most serious problem, women are not treated in a way that respects their right to informed consent.  Routine procedures are administered without asking the patient or explaining what they are for.  If the woman protests, she is seen as challenging the doctor's authority and is labelled as uncooperative.  Most women see the hospital policies as laws and don't feel like they have the right to go against hospital policy for example to decline an episiotomy or request to nurse their baby immediately after birth.  I have also heard stories that amounted to abuse, such as not allowing a woman to see her baby for many hours or scolding a woman for wanting to birth in an unconventional fashion.

How Women Feel
Many of the things I've said about the situation here are not very encouraging when it comes to my personal perspective.  I think what they are doing is far too medicalized and many of their procedures (not to mention their attitudes towards patients) are genuinely harmful.  Having said that, I have asked some women around the neighbourhood how they felt about their birth and most seemed kind of okay with it all.  I think that's partly because they don't know anything else.  Popular culture tells us birth is scary and painful, so when that's what they get, they're not surprised. Its also in some cases because they genuinely believe that what the hospitals offer is great care.  Once again because of cultural conditioning, they believe that a short labor is better (since it's painful and difficult anyway, using drugs to speed it up must be good, right?). And, those who have means are happy they can bribe a doctor for an elective C-section and skip all the horror. Some of those who are poor may simply be happy to have any access to maternity care, since the alternative would be an unassisted birth.

Those who know more about the situation from family or previous births may just accept whatever the hospital does and live with it.  They may know it's bad but they take an attitude of non-resistance as a way to get through.  For example, if you know delayed cord clamping just isn't an option, you don't trouble yourself to make a fuss and ask for it. Just like I don't usually bother asking the taxi drivers at the airport to use the meter.  I know they aren't going to do that and they will charge about four times the normal rate and if I argue with them, I'll just end up stressed and anxious, so I can't be bothered causing a fuss.  However, I have heard from some women who are really passionate about natural birth.  They really argued for what they wanted and made it happen.  I suppose that's what it takes.  As sad as it is, that's probably what's needed to make a change in the hospitals' attitude.

Of course, I should say that some women may have had a good experience - perhaps they ended up with a more compassionate doctor or they had some kind of social standing and were treated better because of that. 

What can be done?
If a woman wants to have a natural birth in Bosnia that doesn't include many of the standard hospital practices, what can she do?  I believe women need to inform themselves about the situation, about their rights and make their choices known to their caregivers, ideally before the birth.  People should realize that hospital policies are not laws they have to obey.  Also, just because they sign something upon admission that says they consent to what the doctors will do does not mean they can't withdraw their consent. It should be possible to make a signed statement withdrawing consent if necessary.  In other countries, patients have sued hospitals for assault if a doctor performed, say, an unwanted episiotomy or coerced someone into an unnecessary C-section.  Both hospitals in Sarajevo have nice sounding patient rights published on their websites, so being aware of these rights could be helpful.

But, as I say, it's probably better to make your preferences known before the birth, as having to argue during labour isn't going to be easy (or helpful for the progress of your labour).  Since it's not necessarily known who will be on staff when you go into labour, maybe it's worth preparing a written document that you can ask as many doctors as possible to read and sign, before the birth.  I really don't know if it would work, but it's worth a try!

Beyond that, the other option is a systemic change - there needs to be a reviving of the midwifery profession here with proper tertiary education and training, there needs to be safe homebirthing options with back-up from hospitals and there needs to be midwife led birthing centres set up.  I focus on midwives because the midwifery profession is about understanding and supporting normal birth.  Obstetrics is a branch of surgery that is needed for complicated pregnancies and births, but when obstetrics takes over all births, it makes normal birth unnecessarily medicalized.

Conclusion
In a country where government services are under-resourced, it seems surprising that a rather expensive, overly medicalized maternity system exists.  The midwifery continuity of care model, including homebirths and birth centres for lower risk pregnancies, would be significantly cheaper.  Perhaps the system reflects a desire not to be backwards - having a lots of ultrasounds and having a C-section are sometimes seen as symbols of sophistication.  Moving towards a new model would take a major cultural change - it would take a greater humility from hospitals that another way is valid and it would take women believing that a less medicalized birth is possible, safe and even enjoyable and progressive.

My journey towards natural childbirth

When I try to recall my first impressions of birth, and where they came from, I can think of a few things.  One is an American movie that my Dad used to like and let me watch a number of times, called "Look Who's Talking".  It's about a married couple who have a baby and all the struggles the couple go through in the process.  Oh, and, when the baby is born, it's really cute and you can hear it's thoughts.  I remember the pregnancy was shown to be a big pain.  The mother was uncomfortable, she was moody and emotional and she was really thirsty all the time.  In one scene she drank a whole carton of orange juice.  When it came time for her labour, the contractions came on suddenly and it was all panic and agony as she rushed outside to hail a taxi, sped to the hospital (yelling at the driver to speed up) and cursed her husband for putting her in this mess as she pushed the baby out.  From watching another movie more recently, it was pretty much the same thing.  Panic, pain, fear.  Who'd want to go through that?

This negative impression was sadly reinforced by my mum's accounts of giving birth to me and my sister. She went a 10 days past her due date, I think, and was told she needed to be induced.  The doctor she had been seeing was busy playing golf when she had the procedure, and so she had to be with an unfamiliar staff, as well as student doctors who frequently came in and observed her.  My mum is a rather modest woman and so I don't think this would have been relaxing for her, to say the least.  Since she was having a chemical induction with the syntocin drip, she really found the pain unbearable, she even said she felt like she was being ripped in half!  Not encouraging stuff to hear as a girl contemplating becoming a mother.

As a teenager, I saw my step-mother give birth to my two half-brothers.  The first birth, my Dad took my sister and I to the hospital just as she was pushing the baby out.  This was a fairly positive experience.  She didn't seem to be suffering.  She was lying on her back, legs in stirrups.  She had had an epidural and when the baby came out, we got to cut the cord.  I was in rapture when I saw the sweet baby, looking around at his new environment, kicking his legs like a little frog.  The second birth, though, I must say, was a bit disturbing.  My step-mother had an induction and the whole process went very fast - she gave birth within two hours!  She decided to try without an epidural this time and only used gas and air towards the end. It was hard to watch, as she didn't seem to be coping too well and became loud.  This from a woman who frequently bears the pain of severe migraines with quiet resignation.  She was in good spirits afterwards, though, and said that the pain didn't matter because it only lasted a short time.

My sister then became a mother before me, at a young age, and she too had a difficult pregnancy with nine months of nausea as well as a long labour that she found traumatic.

All of this left me quite fearful of pregnancy and birth.  When I looked at pregnant women, I thought they must feel like they were sitting on a ticking time bomb as they counted the months and weeks towards the day of agony.  It didn't comfort me to think it would only last a day, or at worst, a few days.  It didn't comfort me that you would forget the pain.  I knew what it felt like to be in pain or discomfort (like when I burnt my hand or cut myself) and even a few minutes feels like an eternity. And, getting a baby at the end is a good reward, but I wasn't convinced it was compensation enough for what people seemed to go through on TV etc.

So, as you can imagine, I was somewhat anxious about the birth of my own baby when I fell pregnant and kind of assumed I would probably have an epidural, and maybe other things too.  However, I had already heard a little about the benefits of labouring without drugs from the time when my mum was pregnant with my youngest sister and I had already heard about the downsides of elective Cesarean section.  So, I hesitatingly began researching more about what natural birth was and it's benefits. As I read more, I realized that it may actually be something I wanted to pursue.

It seemed that every form of chemical pain relief had risks for me and/or the baby.  Just look at the cons listed on this Mayo clinic page.  I also learnt that they can interfere with the birthing process, thereby leading to a more complicated delivery, complicated afterbirth, and can possibly affect the health of the newborn and its ability to breastfeed.  It was really important to me to have a straightforward birth and for my baby to get a good start on breastfeeding.

Still, it took me a while to get my head around the idea of forsaking all chemical pain relief. I never, in fact completely ruled it out, but my hope of having a natural birth increased somewhat when I discovered the concept of hypnobirthing.  It's basically a way of achieving a comfortable, and even painless, childbirth through self-hypnosis.  I had already heard of people using self-hypnosis to undergo normally painful operations if they were allergic to anesthetic, and so I believed it was possible, but I wasn't sure I could achieve that kind of mind control.  I would have liked to have been coached in person and have that person actually attend the birth, but settled for a home-study course produced by "Hypnobabies". This course explained that self-hypnosis consists of two aspects - one is reprogramming the sub-conscious mind and the other is learning relaxation techniques. I'll briefly address each of these.

For the first aspect, the course explains that we all have preconceived ideas about childbirth and that "what the mind expects, it will create".  That is, if we have been trained to believe that birth is painful, we will expect that and then our bodies will experience pain.  Between our conscious mind and our sub-conscious mind, there is a kind of filter whereby we decide what to accept into our deepest beliefs.  In order to disable this filter, we have to go into a hypnotic state (which is basically a relaxed, passive state).  Once in that state, we can listen to positive birth affirmations and learn to believe and accept those statements or "hypnotic suggestions".  This part includes learning a new vocabulary to describe terms associated with birth that are free of the normal negative associations, and which describe birth positively, like "birthing time" instead of labour, "birthing wave" instead of contraction, and never mentioning pain.  Only "birthing sensations" or maybe "discomfort" if necessary.

The second aspect is entering a relaxed, hypnotic state, whereby you don't feel pain, but only "pressure".  Various techniques are used, including visualizations of "hypnoanethesia" spreading around the body, going loose and limp and focusing on deep, slow breathing.  By the way, the breathing that they teach is similar to that taught by the Bradley method.  Both methods also encourage the mother to move freely throughout the labour, which assists the descent of the baby.

Both of these methods work, it seems, because they fit into the physiology of birth.  Firstly, the hormone that initiates contractions is oxytocin.  Adrenaline, the hormone of fear and anxiety, undermines the effectiveness of oxytocin and, according to Hynobabies, fear can cause the lower abdominal muscles to work in opposition to the upper abdominal muscles, causing pain.  However, in a relaxed state, they argue, contractions are not really painful, but just powerful sensations.  Furthermore, deep breathing can reduce pain because it oxygenates the blood and one reason for pain is the accumulation of lactic acid from muscular contractions.  Oxygen allows the lactic acid to be broken down.  Finally, there is this thing called the fear-tension-pain cycle.  When you are in pain and fearful, you tense up because you are fearful, which increases your pain levels, causing more fear and so forth. The more your fear pain, the more pain you are in. So, purposefully relaxing, even if you are fearful or in pain, can reduce your overall pain and also release natural painkillers, endorphins.  Other things, like being able to move into natural positions in response to the descent of the child, swaying the hips, being in a darkened room, surrounded by familiar, reassuring people, can reduce fear, increase relaxation, and increase the release of natural pain killers whilst allowing labour to proceed without 'stalling'.  

The reasons for all of these are well documented in lots of places around the web, so I won't go any further into it, but it's a very interesting area.  Basically, when women are not conditioned to fear birth, are with supportive care givers who can minimize fear and the woman is free to labour and birth as she instinctively wants to, her natural ability to birth shines through and medical intervention is needed far less than it is administered in hospitals.  Giving birth in this natural way, where the natural hormones are not interfered with, can be a very empowering experience, as there is a rush of joy and a sense of accomplishment at the end.

Many of these ideas came across in a number of films, articles and stories I read and these gave me confidence that I could have a positive birth experience.  But, I came to realize that my best chances for achieving this involved finding a place to birth where I could control the circumstances to some degree and fully relax.  I would also need to be somewhere where they wouldn't interrupt my concentration during hypnosis. I imagined getting to hospital and having to fill in forms (in a foreign language) and having all sorts of exams and tests... not to mention if I didn't feel comfortable with the way the staff treated me...this would definitely break my concentration and maybe set off the fear-tension-pain cycle in a major way!  And, if this article about the situation in Serbia is true and if Bosnia is anything like this, I had good reason to run away as fast as my pregnant belly would allow.

Another part of the Hynobabies course involved staying healthy during pregnancy to reduce the likelihood of complications.  And, it presented a lot of information about routine hospital practices which can increase the likelihood of complications and make it harder to have a comfortable birth.  Through this, I realized that having a natural birth was not just about avoiding pain medication, it was also about not interfering unnecessarily in the physiological processes.  I say unnecessarily, because there is certainly a place for interventions, but it seems that hospitals apply them far too broadly based on their own convenience or on population data that doesn't adequately consider the individual case of each mother and baby. Furthermore, once you have upset that balance, the body often needs further medical help because you have taken away what the body needs to do what it's meant to do. Once you get on the bandwagon of interventions, you basically can't get off.  For example, if you have had interventions and pain medications in your labour, it is safer to have a 'managed' delivery of the placenta.  However, if you have managed to stay drug free, a natural 'third stage' is quite safe. See here.

Another big example of one procedure leading to another is induction.  That is, starting labour artificially. The worst kind is with a syntoccin/pitoccin (artificial oxytocin) drip, although other methods can also be quite nasty.  Syntocin (which is also used in 'augmenting labour') really interferes with the body's ability to produce it's own oxytocin, thereby majorly disrupting the body's own management of the system.  Syntocin contractions are said to feel much more painful because the drug doesn't affect the brain in the same way as oxytocin.  Since it's more likely that the baby goes into distress with an induction (because of the intensity of the contractions), the baby's heart rate needs to be continuously monitored, which means the mother becomes basically strapped to the bed, and this itself increases the sensation of pain.  There are also risks for the mother in overstimulating the uterus and uterine rupture is possible.  Also, once you have had this kind of labour, you are more likely to want an epidural to manage the pain, which can lead to difficulties pushing, which can lead to tearing or instrumental delivery.  First time mothers who are induced are also more likely to need an emergency Caesarian section. There are many articles talking about these risks (e.g. this).

Although there are some valid and neccessary reasons for inducing, the most common is for "prolonged pregnancy".  Take a look at this article from Midwifethinking and this article from the perspective of famous midwife Ina May Gaskin for more information about inductions for being 'overdue' and how it's not always neccessary.  I was hopeful to avoid an induction, and that is one of the reasons that I felt the need to have a private midwife who would be more responsive to my individual situation and health and not feel the need to arbitrarily send me for an induction if I went too far over my due date.

There are many other hospital procedures like that, many of which can interfere with the birth process, but which can be hard to fight if the hospital insists that these are it's policies.  For example, the routine use of glucose drips that restrict movement and potentially cause hypoglycemia in the baby, prohibitions from eating during labour, continuous fetal monitoring, restrictive ideas about how long labour or pushing can safely last, not allowing waterbirth, insistence on performing episiotomies, coached "purple" pushing, restricting movement during the pushing phase and insisting on an actively managed third-stage (birth of the placenta).   Also, it is important to consider a hospital's policies for dealing with complications, such as waters breaking hours before labour, the presence of meconium, breech presentation, or having a vaginal birth after previous Cesarean section.  These situations are not necessarily emergencies, but many hospitals have extreme stances on them.  Not to mention the way the hospital treats the baby when it's born, such as early cord clamping, taking the baby away from the mother for tests and examinations immediately after birth, bathing the baby (washing away beneficial bacteria and healthy vernix coating), giving formula instead of allowing the mother to exclusively breastfeed, observing it in the nursery away from the mother, routine injections that may not always be necessary, and so on.  I know that not all hospitals have all of these policies, but most have at least a few of them, which is why I became wary of hospitals.

The more I thought about it, I also just didn't like the idea of being in a hospital.  I felt that simply being in the place for sick people would make me expect pain.  Staff looking at me, expecting me to have pain, would also make it more likely for me to play that role, and this would also increase the sensation of pain.

Isn't that a bit risky, you may ask?  Well, generally speaking, physiological birth is safer.  Even hospitals will tell you to avoid coming in too early because that way, you will be less likely to be given medical procedures, which even they acknowledge, do tend to increase risk. Only when the risks of interventions outweigh the risks of complications that have arisen are they beneficial.  Furthermore, examples from the animal world can be very enlightening. I once read a story of how a breeder of valuable racehorses knew never to intrude on the labouring mare, as interfering risked the saftey of both mother and child. The veterinarian would simply hide and secretly observe the mare and only intervene if there was some major deviation from normal.

Through much investigation, I realized that a good midwife does very much the same thing as the veterinarian I described. She is an expert in normal birth.  She is is not trained to address major complications, but does have the experience to spot them before they become critical and can refer the expectant mother to specialist care.  As I was quite healthy and having an uncomplicated pregnancy, I felt I would be safe birthing in the comfort of a home environment with an experienced midwife.

I must admit that the leap to deciding to have a homebirth (and not just at a birth centre) was a bit scary.  It was partly precipitated by not having access to a birth centre (by the time I arrived in Australia, the only one in the city was fully booked), but it was also that I felt I would have more choice in regards to how I could respond to various potential (minor) complications.  Even birth centres have policies that can be overly restrictive when it comes to things like waters breaking early or going overdue. And, when deciding to stay at home, I was reassured by being very close to a hospital in case something went wrong. Finally, I had a very supportive husband who was, at times, even more enthusiastic about homebirth than I was!

Towards the end of my pregnancy, I started to think about having an empowering birth, not just a safe and comfortable one.  I started to move a little away from the hypnobirthing philosophy.  Maybe it was due to the influence of other mums I spoke to, maybe it was because I couldn't keep up with practising hypnosis five times a day!  I still believed that it could be possible to control your mind such as to eliminate pain but I also considered that maybe, learning to accept some pain and surrender to it with courage was part of God's way of preparing the woman to become a mother, a rite of passage in a beautiful, transformative process.

In the end, I did experience discomfort, maybe you could say pain, but I found it really manageable, and it was very healing to see that the negative image of birth I had received didn't have to be true for me. I wasn't excessively anxious or fearful.  I was patiently awaiting the arrival of my baby. The hypnosis techniques, as well as breathing deeply, really helped me to stay calm. There were times when I felt like it might be getting too much, where I thought it might help to yell out in pain. I tried this, but I could feel it instantly increased my heartrate, increasing fear and making me feel out of control and in more pain.  So, I stuck to being quite, breathing through it and visualizing positive things, like being with my baby in a "special place".  When I felt huge pressure opening up my cervix, I tried to imagine a romantic encounter with my husband on the beach. I think this helped!  In addition, using comfortable positions, being in the dark, listening to soft, gentle music and immersion in warm water all helped me to stay calm and manage the sensations.

For most of my pregancy, I found it hard to get my head around the idea that I was becoming a mother. In the first trimester, I didn't even allow myself to think too much about being pregnant, as I knew the risks of miscarriage were higher.  By the third trimester, I was enjoying being pregnant and I liked the look and feel of my big belly.  I looked with hope to the birth of my baby, but also with much trepidation, wondering if I was ready for this huge responsibility.  Even around my due date, when people asked me if I was sick of being pregnant, I said "No, I like being pregnant", maybe because I still felt a little unprepared.  So, I think I needed the long, quiet, contemplative labor I got.  Even the pain served a purpose of making me feel grateful for the gift I was about to receive, and when I got through it, the sense of accomplishment made me feel really strong and happy. I certainly needed that strength in the early days to get through the rigors of early parenthood, what with post-partum soreness, sleep deprivation, the steep learning curve of settling a baby and breastfeeding through painful nipples.

All in all, I got the birth experience I wanted.  It was a beautiful, empowering journey into motherhood.  I'm truly grateful for this because I realize that many women are not entirely satisfied with their birth experiences. I have read articles which say that the pain of labor doesn't matter because you forget it afterwards and you are rewarded with a beautiful baby.  I think this is not entirely true.  There is evidence that women who suffer traumatic births are at a higher risk of post-partum depression and even post-traumatic stress disorder. This kind of trauma can result from fear that hasn't been addressed, from environments that promote fear, from unnecessary interventions that cause complications and from inhumane protocols.  For many women, their birth experience reverberates not only into their early parenting, but also into the narrative of birth they share with their children, and so the negative image of birth persists.  It can also affect their desire to have more children.  This is such a shame because birth has the potential to be a beautiful experience.  That is why I feel motivated to share what I have learnt about birth in the hope that together, we can help create a system that respects physiological birth.

Birth in Bosnia - Some pros for natural birth

My previous post looked at birth in Bosnia from the perspective of episiotomy.  I think this example demonstrates how the system is bogged down with bureaucracy which is perpetuating outdated and non-evidence based care.  Nevertheless, I realize that there are probably many caregivers who long for change but are too overworked and underpaid to be able to do so.  It's also not surprising that women are put "on the clock" and subjected to restrictive policies due to financial and time constraints.

Nevertheless, I think there are some positive aspects to the current situation that deserve a mention, especially if you're looking to have a natural birth.  Here are some things I have gathered about the system, which seem quite positive for someone hoping for a natural birth, and there are probably more I've missed.  I hope to learn more about the situation in the coming months.  By the way, most of them apply to the Bosnian national hospital, Abdulah Nakas.

Baby Friendly Initiative
Abdulah Nakas hospital is a "baby friendly" hospital. It is an initiative of UNICEF and the WHO designed to promote breastfeeding.  It includes allowing the mother to have skin to skin contact with the baby immediately after birth and to keep the baby with her afterwards, "rooming-in", rather than have the baby kept in a nursury.  Also, the baby is not fed anything a part from breast milk and is not offered a pacifier.  I'm not sure how it works at the other hospital in terms of promoting and actively supporting breastfeeding.

Episiotomy
My previous post looked at this issue. I mentionned there, but perhaps it's worth emphasizing that it is only routinely done for first time mothers.  I've read a couple of birth stories where the midwife massaged the perineum during a subsequent birth to prevent the need for an episiotomy.  Still, the post gave the impression that episiotomy is the norm and it's something special if it is not used, and that is rather disturbing...

More flexible timelines
According to a second-hand account, Abdulah Nakas is a bit more generous in how long they will allow a woman to labour before trying to speed things along somehow.  Perhaps this is because it is a bit less busy than the other one in Jazero?  Just a guess.

No epidural
When I first heard this hospital didn't even offer epidural, I thought that must be a sign that they were more supportive of natural birth than other hospitals in Bosnia and maybe than others around the world.  That may be the case, but it's also possible that they simply haven't evolved since the time when epidural wasn't invented or they don't have the financial resources to pay an anesthesiologist.  I guess that would have implications for how many c-sections are done, and if they are done, how they are performed.  The other hospital in Sarajevo does offer epidural.

No continuous monitoring
According to the Dr. I spoke to, they don't usually do continuous fetal heart rate monitoring, which is a good thing, because continuous monitoring is known to falsely show signs of distress, increasing the likelihood of unnecessary interventions.  Instead, they take the heart rate intermittently.

Water Birth
Abdulah Nakas is the only hospital in Sarajevo that offers water birth.  This does seem like a great way to have a comfortable, natural birth.  However, my impression is that the staff are not in general comfortable with this kind of birth, as evidenced by the fact that they only allow you to use the pool for two hours and also that they still think an episiotomy should be performed in the water.  That is very strange, as the water itself helps soften and stretch the perineum.  So, I'm not convinced this is really as good as it sounds.  I'm happy to be proven wrong, though!

Skills for handling complicated cases more naturally
A friend of mine had a vaginal breech birth at this hospital about 10 years ago, so it was possible then and may still be.  This seems to show that the Drs there have skills that valuable.  In many places around the world, Drs are not taught how to handle vaginal breech birth; they are simply instructed to recommend a C-section when a breech presentation is discovered.  If it is taught, they are still afraid to do it, as the safety of vaginal breech birth is under debate.  However, it is very important to have care givers who are skilled in this area, as a baby can turn breech during labor and this can go undetected until it's too late.  Furthermore, breech birth doesn't have to be an emergency if the care giver is calm and experienced.

It does appear that vaginal birth after C-section is allowed, though perhaps there are restrictions I'm not aware of, such as perhaps how close the previous birth was.

Also, it seems that many Drs will support vaginal birth of twins, something that is also not always supported in other parts of the world, such as some hospitals in USA.

Birth in Bosnia - Episiotomy

Episiotomy... that's a word I had never heard before becoming pregnant.  In fact, I may not have even come across it were it not for one fateful evening at my Bosnian language class.

I was attending a small language school in the neighbourhood and, although my teacher was quite dedicated, the few number of other students were not, and so for not the first time, I was alone with Sandra, our teacher.  The conversation turned towards my pregnancy.  I was starting to show, so I was talking more about it with people.  At this point, I was planning to stay in the country for the birth.  I had already researched a lot about natural birth and knew that I wanted this.  My impression was that it would be possible in Bosnia, as one friend mentioned that the hospital where she gave birth didn't even have epidurals, so that seemed promising.  Nevertheless, we had done little firsthand research into the situation, so I was quite pleased when Sandra started talking about her sister's birth experience.  After a little while, she paused and said, "Now, I don't want to scare you, but I think there's something you should know.  When my sister called us from the hospital to announce that she had had the baby, my grandmother asked to know whether my sister 'had been cut'.  She said 'yes'. My grandmother said, 'oh yes, they always do that in Bosnia'."

As I walked home alone, along the cold, dark streets after class, I became filled with a kind of terror.  I felt unsafe and violated as I imagined the Dr. cutting my vagina.  When I got home, I googled "cut vagina birth" since I didn't understand what this cutting business was. I eventually figured out that what Sandra meant was an episiotomy - a practice whereby the skin between the vagina and the anus (the perineum) is cut as the baby's head is born.  I saw that it was routinely practiced in the 1950's, as they believed it made for an easier delivery, as it widens the birth canal. It was also thought to prevent severe perineal damage during birth and heal better, since it easier to stitch up than a natural tear.  Since then; however, it has not been practiced routinely in places like the UK and Australia because it was shown that it does not prevent severe tearing, and in fact, it could even lead to more severe tears.  It does not heal faster, is more painful than a natural tear and may even cause bladder and bowel control problems in future. More enlightened care givers view episiotomy as excusable only during an instrumental delivery (forceps or ventouse), which I think should also be a rare occurrence, or when a more speedy delivery is needed because the baby is in distress.  If Sandra was right, and they were still practicing episiotomy on all women, regardless of whether it was truly needed or not, this reflected very badly on the state of birth in Bosnia.

This was when I started to question whether I would be prepared to birth in a Bosnian hospital.  Sandra's revelation had really scared me and so it set me off on a quest to know if it was true and to see what else was routinely done in Bosnian hospitals.  I managed to talk to a few more women about their experiences and I was not very comforted.  I finally was able to see a Dr. at Abdulah Nakas hospital and asked him a number of questions.

Episiotomy scissors

He was very surprised that I didn't want him to examine me or give me an ultra-sound.  I guess it was very unusual for him to have patients who wanted to ask questions or go through a birth plan with him.  I calmly went through my list, as he sat there bewildered and amused at the strange foreigner.  For example, "Can I eat during labour?", "No, you might get nauseous and vomit and choke on your vomit", "Can my husband be there for the entire labour and birth?" "Not the labour, but part of the birth" (or the other way round, it wasn't clear), "Can someone else be with me who can translate in case it's needed?", "No. Everyone speaks English".  He said that despite the fact that he already misunderstood several of my questions and sitting next to him was a non-English speaking nurse.  "Can I have a water birth?", "Yes, but you can only stay in the water for two hours"... By this point, my opinion of the hospital wasn't too good.  I felt that many of the hospital rules were outdated and unnecessarily restrictive.  The fact that waterbirth was possible was definitely a plus, but combined with the rest, and the hospital's approach in general, I wasn't too hopeful about my chances of having the kind of experience I wanted.  This was confirmed when I asked about episiotomy. "Yes, all first time mothers need an episiotomy." "Why?" "Because you don't want to risk tearing and it heals better than a tear." "What about if you have a water birth?" "Oh, we can still do it in water." "Really, you can do it in the water?" "Yes, of course.  Trust me, I'm a surgeon."

Exactly, you're a surgeon, I thought.  That's why you shouldn't be handling normal pregnancies and births!  Your very useful skills should be reserved for when normal has turned pathological and the woman's body can no longer do what it normally can.  But that's the thing, I don't think he, and many other obstetricians (obstetrics is a branch of surgery), do trust a woman's body to do what it was designed to do.  That was essentially why I decided I needed to find another place to birth.

"Trust me, I'm a surgeon." At the end of the interview, he acted like he had done me a huge service by answering my questions.

In the end, Lessan and I decided to return to Australia and have a homebirth there, attended by a midwife.  A midwife is not a surgeon, she is someone who has been trained to assist normal births. It seems that, although there are midwives in Bosnia, they only practice in hospitals under the control of obstetricians.

And, as I side note, I now realize that it is difficult for hospitals to offer truly respectful care, as they are often affected by business models of functioning and so, even in places like the UK where midwives are basically in charge in hospitals, the situation is still not ideal.

Upon returning to Bosnia, a friend of ours, Maja, told me about her birth.  She noted that the hospital did everything according to a "need for speed". She had a very painful (unwanted) episiotomy that left her in severe pain for weeks and then discomfort until six months post partum! Of course, everyone's experience is not as bad as hers, but still! It now seems to me that performing episiotomies, like many other interventions, is based on hospital convenience.  The pushing phase, in a first time mother, can sometimes take three hours (and this is normal), but if an episiotomy is done, the baby can come out much faster. This is not only painful, traumatic and unnecessary for the mother, it could even be dangerous for the baby if they try to pull it out in the process.  I don't know if they do this, just theorizing here, but if they did pull it out, it could force the baby to come out at angle that causes it to 'get stuck', i.e. shoulder dystocia, which is a major problem!  Furthermore, Maja said she had asked not to have the episiotomy.  They said, of course, we only do it when it's needed.  They let her push for a while and then said that it was best to do the episiotomy to make more room.  This strikes me as the hospital not having faith in a woman's ability to birth her baby, in what was, as far as I can tell, a normal birth situation.

During the pregnancy, I sometimes felt guilty about going to the effort we did to have a good birth experience, but now I don't.  It was very worth it, as it was such an empowering experience that gave me so much confidence to proceed down the path of motherhood.  And, by the way, I ended up having a natural tear during my birth.  I didn't even notice it happening and I healed quickly, even with needing a couple of stitches.The sad thing is that I shouldn't have had to make such an effort to have a natural, undisturbed birth.  Every woman should have access to respectful, empowering care for her birth.  Interventions, like episiotomy, are wonderful if truly needed, but we should be wary of any 'routine' intervention in birth because birth is not a medical event needing to be managed, it is the body performing a function it was designed to do.