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Intervention is a tricky little word that seems to divide midwives. Most midwives agree that midwives in general use less “intervention” then physicians. But that seems to be where the agreement ends. What makes some midwives feel a woman can be successful at an intervention free birth in a hospital, while others believe even women giving birth with a home birth midwife receive regular interventions?
The problem arises when using different meanings for the term intervention. Some midwives use the term to mean surgical or pharmaceutical techniques (cesarean, pitocin, epidural). Some midwives use the term to mean anything done to alter the natural course of labor (castor oil, cytotec, tocolysis). I remember being taught that intervention was a all the things a woman didn’t want to have happen when I was training as a childbirth educator. So, what does this term really mean?
To understand what counts as an “intervention” for health, I rely on my understanding of prevention. Why prevention? Because as a nurse this is how I order my thinking about the interventions I use to help a woman achieve the healthiest birth possible. Honestly, every contact I have with a woman is an intervention.
There are three levels of prevention, each with it’s own set of interventions based on whatever risks the woman may be facing.
The highest level of prevention is tertiary. This is when a serious problem has been identified, perhaps a woman has had an eclamptic seizure or the fetal heart tones reveal a prolonged bradycardia. In this case, intervention is focused on stopping whatever is causing harm and minimizing the effects of the problem to help the woman and her child achieve the highest level of health possible. So, with an eclamptic seizure the interventions include safely moving the woman to a recovery position, injecting the appropriate doses of medication to prevent additional seizures, close monitoring of the woman and baby to identify any residual problems.
The middle level of prevention is secondary. This is defined as early identification and treatment of problems to prevent escalation. In this case, interventions include screening to identify woman and babies at risk as well as all the things done to help minimize any risks identified. An example would be identifying a mother’s blood type. If the mother is Rh- blood and the father is Rh+, Rhogam can be used to help minimize the risks for the next baby. Taking a history during a prenatal appointment and screening tests are interventions for secondary prevention because they help identify health issues for the mother or baby. Taking blood pressure, monitoring the fetal heart tones by any method and monitoring the progress of labor are all interventions for secondary prevention.
The first level of prevention is primary. These are the things that are done to prevent a problem from starting in the first place. This includes most education I would give a woman, such as educating a woman about her nutritional needs so she can improve her diet as necessary. Another example could be offering an influenza vaccination. During labor, ensuring a woman stays adequately hydrated is a primary intervention because it helps prevent problems.
To help you get these concepts, here are a few more examples:
During labor, I recommend a woman change positions regularly as a primary intervention because I know it will help labor progress normally. If, during labor, the mother begins to have a backache, I may recommend certain positions as secondary prevention because I know she may have a baby in a posterior position and these positions will help relieve some of her pain and help the baby move.
During pregnancy (and as she is planning her pregnancy) I recommend a woman maintain optimal intake of folic acid (perhaps through a prenatal vitamin supplement) to help prevent neural tube defects – and this is primary prevention. If, during pregnancy, screening reveals a woman is anemic I may recommend an iron supplement as secondary prevention to help rebuild her iron stores and avoid the problems anemia can cause during the post-partum.
Is everything really an intervention?
Yes, everything I do as a midwife is an intervention on one of these three levels. This is because everything I do has a specific purpose – to help a woman make any necessary changes to have the healthiest pregnancy and birth possible. Providing education so she can make lifestyle changes is an intervention. Screening to give her information about the state of her health is an intervention. Responding quickly if there is a problem in labor is an intervention. This is true whether I do this work in her home, at a birth center or at a hospital. This is true whether I provide the education as a midwife, nurse, doula, or childbirth educator.
I hope you see “intervention” is not a word to be afraid of, and in the purest terms, an “intervention-free” birth is only possible for women who choose to give birth alone. Even women who hope to achieve a natural birth do not generally mean they want to avoid the interventions of the midwife listening to the baby’s heart tones or recommending things they can do to be the most comfortable. A birth does not need to be intervention-free to be natural.