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  I think this example demonstrates how the system is bogged down with bureaucracy which is perpetuating outdated and non-evidence based care.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.