Rivista per le Medical Humanities

Mara Bianchini
rMH 41, 2018, 15-16

Well-coming to the world. Introductory notes

The reflections on the birth carried forward by the “Nascere Bene Ticino” Association are part of the perspective of a new paradigm of care that affects all health care areas. In the field of obstetrics, however, this perspective also raises particular questions about the interaction between the quality of the care relationship and the quality of care itself, as well as raising some others of a more general nature concerning the place of the woman and of the woman’s body in our society. Consequently, such reflections also concern the need to activate a kind of obstetrics based on the art of maieutics and on the scientific evidence that promote their application, so as to avoid any unnecessary trauma to the mother-to-be and to the human being that is making its appearance in the world. Respecting the continuum of its pre- and perinatal experience helps preserve a psychic ground upon which its ability to love can grow more easily.

Silvia Vegetti Finzi
rMH 41, 2018, 17-22

The conspiracy of silence

The generative power of women has always aroused in men contradictory emotions and feelings, ranging from admiration to envy. The author explains us how the mother’s role during childbirth has been belittled and, in our culture, put in the shade by the misogyny of Western man, as just an unspeakable and invisible experience. With the transition from the “maternal” social organisation of archaic agricultural societies to the political-military “paternal” one of the Greek polis, as well as of the Judeo-Christian one, the “true” birth of Western subject is separated from childbirth, through the rite of recognition and acceptance in the world, according to an all-male genealogy. Childbirth is thus also banned from the space of the sacred sphere. Any feminine knowledge has been undermined, thus removing the connection between birth and death as referred to by childbirth as an event belonging to the inexorable natural laws that govern the biological cycle and link man to the kingdom of nature and, therefore, to the mortal determination resulting therefrom. Today, the language of childbirth belongs exclusively to medical science.

Laura Bertini-Soldŕ
rMH 41, 2018, 23-28

Birth rituals and cultures

Birth is a cultural event, as well as a biological one, which involves both individuals as such and the community as a whole. The beginning of life is a biographical transition preceded by a series of both biological and cultural events. The sometimes original and some other times traditional knowledge and techniques that come to the aid of people when it comes to dealing with this event are the true focus of the contribution aimed at exploring what ultimately makes this experience a shared one: the quest to control and manage the uncertainty and mystery that envelop birth, ensuring health and prosperity to both mother and child. The challenge that emerges from the proposed analysis is to improve symbolic effectiveness in accompanying childbirth as well as in prenatal and postnatal care through cultural mediation.

Michel Odent
rMH 41, 2018, 29-34

What makes birth in the human being special?

Birth is for all mammals an involuntary physiological event, controlled by archaic brain structures that produce the hormones necessary for its functioning. Usually, in case of danger, this process is interrupted and can be resumed as soon as the necessary safety and privacy conditions are restored. However, there are important differences in the bacteriological – and, therefore, also immunological – field, as well as in the field of brain functions. For instance, newborn mammals other than humans, having received no antibodies, must immediately have access to the beestings to survive. The human placenta, on the other hand, is already able to transmit many antibodies from the mother to the foetus, which is therefore protected in the event that the bacteria it comes into contact which immediately after birth are familiar to it. But today it is no longer the case, and it cannot be excluded that this change should be deemed correlated with the increase in diseases related to immune system disorders. Moreover, only in human being has the neocortex developed, i.e. a part of the brain that, when activated, inhibits the more archaic part, which, therefore, also causes the delivery to be more difficult. To promote the physiological mechanisms in the woman in labour, it is therefore important to take into account the bacteriological environment and avoid any cultural conditioning and interactions capable of stimulating her neocortex (e.g. language, light, visual contact, presence of strangers observing, judging, disturbing...) or her adrenaline production. In other words,   during childbirth, the key concept is privacy protection.

Delta Geiler Caroli
rMH 41, 2018, 35-44

The controversial issue of safety

The concept of safety in obstetrics is usually linked to the mortality and morbidity risk for the newborn and the mother, a risk that becomes very high in poor countries and in lower social layers in general, now reduced instead to historical lows in high-income countries, thanks to the considerable increase in well-being, hygiene and obstetric technology in case of complications. In parents’ and caregivers’ decisions, safety certainly remains a fundamental choice criterion, but, at a subjective level, perception of risk varies quite a lot. Actually, birth is often still narrated, represented, and internalised as a painful and dangerous event; that is why the hospital environment is generally considered safer, although but this – perhaps – is not always the case. There is no unanimity on the ideal size of hospitals, nor even on the safety of in-hospital and out-of-hospital childbirths managed by midwives. One thing for sure is that the frequency of medical and surgical examinations and operations (in fact sometimes useless or even dangerous) has increased, being favoured by a blurred distinction between physiology and pathology, and between doctors’ and midwives’ skills, respectively. The consequence is that, in the name of a presumed risk, an experience of a sacred nature that plays a fundamental role in the life of its protagonists, as is the case for birth, is being increasingly reduced to a purely medical act. However, is it possible to guarantee safety by avoiding the iatrogenic effects of over-medicalisation? It seems possible, given that the rate of infant and maternal mortality and morbidity does not depend so much on the place chosen for delivery, as on the care system and on the quality of the care relationship instead.

Mara Bianchini
rMH 41, 2018, 45-53

A mysterious discrepancy

What drives the choice of clinical practices commonly used in obstetrics? Recently, different voices have agreed in denouncing the increase, over the last twenty years, of unnecessary clinical, instrumental or surgical interventions in the physiological process of delivery in women without pathologies, with the purpose of causing, accelerating or medically managing birth. In order to counteract this trend, the who published in 2018 a long series of new recommendations based on the revision of updated scientific evidence, which contradicts in several points the protocols currently implemented in our hospitals. While today medicine tends, as a rule, to minimise invasive interventions, it is inevitable to wonder what are the causes of this counter-tendency in obstetrics, of this over-medicalisation in an area that is rarely pathological. Reducing explanations to economic and organisational factors or to defensive medicine is not enough: deeper and more complex causes that alter the quality of the relationship in the accompaniment must be investigated. To prevent over-medicalisation, it would be useful to distinguish cases at risk from normal cases, differentiating protocols and personalising clinical practices in maternity wards, which are essential conditions to promote a physiological course so that birth becomes a good experience.

rMH 41, 2018, 54-55

Caesarean section clinically indicated

From the clinical point of view, abdominal delivery is positively evaluated, yet some studies emphasise the human price of medicalisation and its impact on maternal attachment. On the one hand, the caesarean section has increased safety in cases of complicated delivery, but, on the other, it has transformed the experience of birth into a technical and impersonal act and the pregnant woman into a passive patient. We therefore easily understand the importance – in cases where surgery is necessary – to favour a globally positive experience through practices based on an integrated health concept and respectful of the mother-child bond and of the psychophysical needs of both. For example, in some countries and hospitals, women may ask for the “Charité caesarean”. Its novelty consists in integrating some benefits of vaginal delivery in surgery without giving up safety. Unlike what usually happens after an abdominal delivery, the Charité caesarean is remembered more as a birth than as a surgical operation.

Janine Koch
rMH 41, 2018, 56-63

A different perspective: birth from the child's point of view

Why do most children cry at birth? What do they want to say? Newborns’ cry is communication, they wants to tell us something urgent and important. They tell us their story, tell us about their journey in leaving the womb, their meeting with the cervix initially closed and the passage through the pelvis up to the light, of difficulties, fears, pain, and separation. All prenatal, birth and early-childhood experiences are recorded in the form of implicit memory in the limbic system of the brain, which is responsible for our emotions and sensations, thus creating a limbic imprinting. From a physiological point of view, prenatal and perinatal traumas remain imprinted as patterns in the nervous system, the connective tissues, and the body structures. They can influence the way the child and the future adult will feel and function. Birth is one of the most powerful physical experiences in life, during which the mother’s body and the child’s body interact continuously. A troublefree pregnancy, a sweet birth with a spontaneous labour, free from violence and without detachment from the mother, accompanied by the one-to-one assistance of a qualified and trustworthy person who conveys to the mother-and-child dyad safety and tranquillity, reinforces their bond and helps create in the child a solid psychological ground of trust in life and in its own strength. A good birth is therefore a precious investment in the psychophysical health of every human being.

rMH 41, 2018, 64-70

When childbirth leaves an open wound

Birth in general is a joyous event, but it can become a traumatic experience and be experienced as violent. If in the past women were powerless in front of nature, now, with the advent of technology, they can feel helpless in the face of invasive interventions on their body. The unscrupulous use of a set of procedures that are not risk-free – i.e. inductions, pharmacological accelerations, episiotomies, caesarean sections – exposes the woman’s body to intensive manipulation, often accepted with fatality in the name of “safety”, but experienced intimately as an amputation of female power. In literature, the experience of violence is associated with operations undergone passively, taken for granted and deemed painless by doctors or perceived as unnecessary. Maternal well-being, on the other hand, is linked to the support received, the quality of information, the perception of control, and empowerment. Various sources confirm the effectiveness of specialised midwifery and of a global caregiving model that encourages as far as the normal reproductive processes, enhancing women’s resources as well as the instinctual, sexual and experiential aspects of birth. Childbirth is a positive event when the woman is able to clearly feel both the limit and the strength of her body.

rMH 41, 2018, 71-76

New trends in Swiss obstetrics

Something is changing in Swiss obstetrics for various reasons, including the need to expand the supply of hospitals while reducing health costs, the need to distinguish more clearly physiology from pathology and the related forms of assistance from two professional figures with complementary skills and specialisations. In many countries, the health authority is now rediscovering the key role of midwives, as experts in physiology, thanks to the benefits and savings obtained through their continuous accompaniment throughout the motherhood period (including childbirth itself) of women who do not present risks. In Switzerland, there are cantons where the proportion of nonmedicalised parts is already much higher compared to the national average, alongside others where, on the contrary, it is rather insignificant, probably due to the lack of offer. Some hospitals, however, are beginning to propose non-medicalised delivery, and the Swiss Federation of Midwives has already developed the basic criteria for the introduction and recognition of in-hospital or out-of-hospital models that offer the opportunity of natural childbirth managed by midwives. Meanwhile, due to the concentration of medical specialities in large hospitals, many small maternity wards are being closed down and, in some regions, the only alternative remains the creation of birth homes. In Ticino too, a birth home has recently been opened, and home childbirths are on the increase, although, in order to offer free choice to the majority of women – who prefer to give birth in hospital –, it is still important for hospital maternity wards to complete their offer.

Delta Geiler Caroli
rMH 41, 2018, 77-80

Giving birth in hospital without a doctor is possible

To introduce new caregiving models, pioneer women and men able to anticipate trends and experiment with new solutions are always need. Even in obstetrics, there are some. A number of courageous chief physicians, in collaboration with equally courageous midwives, have introduced in their hospitals the non-medicalised birth in order to restore the dimension of “humanities” in birth, now limited to just the “medical” one. We have chosen some interesting examples, different from each other, and we wanted to know what are the grounds for this choice and how the collaboration between doctors and midwives actually works. Dr. Gabriella Stocker, chief physician of obstetrics at the Triemli Spital in Zurich, presents the system of independent accredited midwives and of the service of delivery managed by internal midwives. Dr. Monya Todesco, chief physician of obstetrics at the Cantonal Hospital of Aarau, explains why she created a space specially intended for natural childbirth managed by independent midwives in a small house located just near the clinic. Dr. Johann Anderl, chief physician of obstetrics at the Frutigen regional hospital, and the midwife Lidije Berisha reveal why in their hospital all childbirths are accompanied only by accredited independent midwives and there are no longer any internal midwives. Finally, Dr. Yvan Vial, head of the department of obstetrics at the University Hospital Centre of the Canton of Vaud (CHUV), motivates the forthcoming creation of a hospital birth home.

Bernard Borel
Gérald Fioretta
rMH 41, 2018, 81-83

Aquila midwives group Natural childbirth: hospital versus birthing home

For more than 15 years now the Hôpital du Riviera-Chablais/ Vaud-Valais/Suisse (hrc) has hosted the “Aquila” birth home, self-managed by a group of independent midwives. At the same time, the Aigle premises of this public hospital include a department of obstetrics intended for births with a population of about 90,000 inhabitants. A group led by the paediatrician Bernard Borel and composed by the midwives of the “Aquila” birth home of Aigle and by an epidemiologist expert in statistics, analysed the perinatal results of the two different places of birth. The retrospective study compares the way of birth, frequency of medical interventions and state of health of the newborn for 912 births started in the birth home between 2002 and 2016 and 788 comparable childbirths occurred in 2007 in the hospital maternity award. The data collected for the two groups compared were corrected and purged, so as to make the comparison possible and reliable. The differences between the two groups, despite the best possible standardisation for comparison, are significant and show a greater respect for physiology in the birth home. The study attempts to draw conclusions and poses the “gold standard” issue for full-term   deliveries and without foreseeable risks.

Catherine Castella Mariotti
rMH 41, 2018, 84-85

Craniosacral therapy. Interview with Rudolf Merkel

The paediatrician Rudolf Merkel, founder of the “Schule für Craniosacrale Osteopathie” (which later on became the Cranioschule) in Zurich, illustrates the problems that may arise during a childbirth and how important it is for the unborn child, both structurally and emotionally, to be able to benefit from adequate care to dissolve tensions. It is also equally important to be able to remedy with early care in the event of difficult deliveries or births with complications that required medical or surgical interventions. The craniosacral method has often proved to be effective for this purpose, and has already been introduced in some hospitals with staff who have attended this training or where reference is made to external specialists.

Roberto Malacrida
rMH 41, 2018, 86-91

What about the prospects for an obstetrics based on scientific evidence, physiology and surgery excellence in Ticino?

We propose the synthesis of some contribution to the discussion at the concluding round table of the symposium entitled “Ceasarean, when how and why?”, organised by the “Nascere Bene Ticino” Association on 17th November 2017 at the San Giovanni hospital in Bellinzona, chaired by Roberto Malacrida. In addition to the two keynote speakers, namely Michael Stark and Michel Odent, other participants were Claudia Canonica (chief physician of gynaecology and obstetrics at the Bellinzona and Valli Regional Hospital), Veronica Grandi (midwife, co-president of the Ticino section of the Swiss Midwives Federation), Mattia Lepori (Medical Area of the General Directorate of the Ente Ospedaliero Cantonale) and Giacomo Simonetti (chief physician of paediatrics at the Bellinzona and Valli Regional Hospital). All contributions agree on the importance of respecting and encouraging childbirth physiology as much as possible without fearing to change clinical practices in accordance with latest evidence, which belies the usefulness of certain routine interventions. However, we should take into account the cultural and individual perception of the risk, improve the collaboration amongst field experts and introduce as soon as possible the small improvements that encourage physiology at no cost.

Federica Tosi Bianda
rMH 41, 2018, 109-112

A mother (doctor) and her three different childbirths

The testimony of a mother, a doctor by profession, on the birth of her three children, born from very different deliveries, including a caesarean section, a suction cup and a completely natural childbirth, and on how these experiences influenced her own life, both as a mother and as a doctor, as well as her children’s. The contribution shows the difference between the knowledge acquired from a classical medical education and that one can gain only thanks to personal experience, which is essential for a healthy childbirth process.

Carmen De Grazia
rMH 41, 2018, 113

Bells and crickets: a home birth

Bones. Blood. Flesh. This is how Carmen immediately describes her home birth. In a sometimes ecstatic state, she tells us how she sees her newly-born child with the eyes of instinct and heart, a bit inebriated with love. The fluid dynamics of the onset of an attachment process occurs naturally and spontaneously. Hers is meant to be a testimony of that relaxed and carefree state that every mother should be able to experience freely when she gives birth to a child. She then adds some reflections on her choice, comparing her first experience of delivery in hospital with that of home birth accompanied by a midwife already well known in advance.

Angela Notari
rMH 41, 2018, 114-115

Heat wave and human warmth: childbirth in a birth home

Angela tells about the birth of her first child, Furio, which took place in a birth home on a warm August evening. Among the walls of the first house in Ticino where mothers can have a natural childbirth accompanied by expert midwives, Angela found respect, professionalism, serenity, warmth, safety and dialogue with other health players (hospital, gynaecologist and paediatrician). That is why today she can define that experience as the most powerful and beautiful of her entire life, as well as a precious opportunity for her (and this applies to women in general) to get to know herself and face birth with freedom, positivity and awareness. To the figure of the midwife – who, together with her husband, played a fundamental role in Furio’s birth process – Angela attributes not only the competence, but also the empathy and listening necessary to establish that precious sisterhood that, during a moment of such great vulnerability, intimacy and importance in a woman’s life, helps enormously and, ultimately, makes a big difference: it turns childbirth into a really pleasant experience, despite the undeniable strength required for opening the body, but above all despite the many negative messages that are often associated with childbirth in our culture.

Veronica Banfi
rMH 41, 2018, 116

The whirlpool and the pool of warm water: an in-hospital birth

Veronica remembers her second hospital childbirth, which happened almost casually in the water, which she experienced with great naturalness, joy and satisfaction. All the more so, thinking that she did not suffer the slightest laceration, even though her little Jacopo already weighed a good four kilos. She had not set herself any particular childbirth model, but knew she could manage it alone the first time, so she asked to avoid any intervention that was not absolutely necessary. And so it was: lovingly supported by her husband, she experienced a second natural childbirth in a hospital of which she has a very positive memory, just as of the first. She is grateful to her gynaecologist for letting her do the way she wanted without intervening.

rMH 41, 2018, 117-118

The weeping mother

A mother chooses to write a letter to her gynaecologist to tell from her point of view the traumatic experience of a caesarean section undergone passively and taken for granted: her truth about her childbirth, which does not appear in the medical record. The narration of a wound, in the body and in the soul, difficult to heal. The narration of an experience of helplessness, difficult to share. The letter also mentions the difficult working-through process through writing that enriched her as a person, allowing her to show herself without feeling exposed, changing her perspective from that of a passive victim of her own delivery to that of an active protagonist of her own story. This process, nevertheless, left behind some open questions.

Delta Geiler Caroli
rMH 41, 2018, 119-120

The umbilical cord blood helped my daughter

The author retraces, over thirty years later, the experience of her childbirth, which took place following her request not to cut the umbilical cord until it had ceased to pulsate, although the rule of immediate clamping was then in force. So the newborn remained “skin to skin” on the mother’s belly, who recalls this moment with immense tenderness. This personal experience is recalled by the author following the moral dilemma expressed by a young woman whether to donate her cord blood to a public bank in favour of other children or to keep it in a private bank for the exclusive use of her family in the event of any serious diseases treatable with stem cells. The delayed cutting of the cord is precisely what, still today, she would suggest to a young woman and to those who are in the same condition as her: a choice aligned indeed with the recommendations of the who and of many other health authorities, which allows a mother and a child not to experience an abrupt separation favouring the attachment, which allows the newborn to still receive oxygen and shift in a softer way to lung breathing, which prevents it from being deprived of up to a third of its own blood and still get from it stem cells and other precious substances (such as iron reserve sufficient for six months), which finally offers it benefits for its immune system. On the other hand, this is a choice that benefits the mother as well, who thus takes advantage from additional hormonal discharges, which in turn promote the contractions necessary for the expulsion of   the placenta.

Davide Melena
rMH 41, 2018, 121

A dad's advice

Davide, as a partner of his second child’s mother, regrets the bad information circulating about childbirth, impregnated with fear and pain, and especially about home birth seen as an antiquated and risky choice. After a first experience in the hospital, he is intensely living that of the home birth, discovering how important it for the couple to get prepared in order to enable the woman to live intensely an experience that marks an important turning point for her self-esteem. He tells with pride of how he really felt a man, an important half of the couple, but also of the feeling of fragility before the generative power of his partner and of admiration for how the latter was able to live this bodily experience in such a natural way.

Anna Fossati
rMH 41, 2018, 122-123

Trust, respect, intimacy and naturalness

This is the intimate testimony of a midwife who accompanies home births as well as births at the lediecilune maternity and birth house in Lugano, the only one existing to-date in the Italian Switzerland. She is usually called at night, and on the way she appreciates the silence and peace that help her recover the serenity and trust necessary to do her job well. Now why, the midwife wonders, in our culture – which is so medicalised –, are there still women who prefer to give birth at home? In the simplicity of their answers, what emerges is the trust in the abilities of their body. Guided by pain, it bends, stretches, expands, and finally surrenders and gives itself up, welcoming the new life that is coming with force. If childbirth is a deep opening of the body and soul, and if we acknowledge that opening ourselves is difficult because we become more fragile and vulnerable, then we understand that it is easier to do it in an intimate and protected environment, like one’s own home. Science, the author points out, is “discovering” how useful what the body can do is: the midwife’s role is precisely to protect the woman from interference while encourage instead the natural process. What a woman who is preparing for childbirth lacks most today are not examinations and calculations of probabilities, but someone who listens to her, supports her and encourages her to feel her own body and her baby’s.

Lena Sutter
Lidije Berisha
rMH 41, 2018, 124-126

Hospital midwives dilemmas

At the Congress of the Swiss Federation of Midwives held in Thun in 2013 two midwives explain how they experience the contradictions between a medical knowledge based essentially on research and the knowledge of the pathology, considered as a potential risk always present, on the one side, and an obstetric knowledge based on the deep knowledge of physiology, on the other side. Relying on some concrete examples, they show how it could be possible to avoid cascade interventions due to interference in the natural course of pregnancy and childbirth. Instead of observing and listening to a pregnant woman, one tries to exclude any presumed risk factor, which legitimises any type of intervention. Obstetric care is by now marked by the fear of not recognising some symptoms and, consequently, being prosecuted accordingly. Today, we must justify ourselves when we do not intervene, whereas in the past we had to legitimise questionable operations and unnecessary interventions resulting in unnecessary costs and, possibly, harmful side effects. Even in the absence of any pathological finding, midwives often feel compelled to apply decisions concerning the intake of medicines and to organise or perform interventions that are in contrast with their assessments.