We all understand that breastfeeding is an activity that feeds a baby and grows a baby. Women who are pregnant undergo complex physiological changes in their bodies that produce colostrum during pregnancy which is the substance for the baby’s first feeds. Once the placenta separates and is born after the baby’s birth the process of lactogenesis 2 begins and some days after this, women start to produce greater volumes of milk in an event colloquially known as the milk “coming in”. This scientific description of the physiology of lactation is the approach commonly taught to health professionals as an introduction to supporting breastfeeding. But how do we support women to breastfeed really?
Breastfeeding rates in western urbanised and industrialised (also known as ‘high income’) countries reflect a reasonably high percentage of women initiating breastfeeding but rates drop away almost immediately with women either weaning or else mixed feeding with infant formula to varying degrees. The World Health Organisation recommends exclusive breastfeeding for the first six months because of the known lifelong health benefits to mother and baby.
So why do women stop or modify their breastfeeding? And what role does the support we offer to breastfeeding mothers play in these health behaviours?
There are a couple of midwifery researchers who have had a dip at finding out what breastfeeding support provided by midwives looks like – warts and all. They did this with a view to thinking about how it might be done better.
Fiona Dykes conducted a focused ethnographic study of midwives supporting breastfeeding in two UK hospitals to find out what breastfeeding support actually looked like. She found that the time constraints of the postnatal wards meant that midwives provided breastfeeding support in a particular way: breastfeeding was ‘managed’ by midwives through routinised practices and disconnected encounters. This can be understood as a reflection of the structures of the postnatal wards (and the hospital itself) which are based on linear timelines and efficiency of work. It turns out – this is not a good environment for supporting breastfeeding women! We know this because satisfaction levels for postnatal care are downdowndown. We also know that the activities of newborn babies and breastfeeding do not subscribe to linear timelines or indeed to any industrial notions of efficiency. Which is why midwives to resort to the previously mentioned approaches.
Elaine Burns conducted a similar study of Australian midwives and women in two postnatal settings with a slight tweak on the methodology – she carried out a ‘discourse analysis’ on the recorded interactions with midwives and mothers and on the interviews she conducted. This means she was analysing the language in these encounters to gain an understanding of practice. Burns found that breastmilk was constructed by midwives as a precious substance – ‘liquid gold’ – that also resulted in a focus on the production and acquisition of that substance. Breastfeeding was also constructed as a natural and easy thing to do – ‘not rocket science’ – which unfortunately meant that if women were having difficulties they were seen as incompetent. Both of these approaches functioned to distance midwives and women and to exclude relational approach to communication and support.
Does any of this resonate with your own experience of trying to offer breastfeeding support in postnatal environments?
Here are a few examples that seem to illustrate this approach. The first one is what I call the “cult of expressing”. We have definitely created a monster here. I feel like somewhere at the turn of the 21st century expressing became a substitute for breastfeeding in hospital. This practice was defended by the idea that all women should learn how to express, but it fits in very conveniently with the above clinical approaches that favour managing breastfeeding as well as valuing breastmilk as a measurable product. With expressing we can all see ‘how much the baby is getting’ and have our anxiety about the reliability (or rather unreliability) of the woman’s body to actually provide for her baby – soothed or else confirmed. And now we can add to this the popularity of antenatal expressing.
Another practice we have is weighing babies on day two after birth and the grading of weight loss into percentages: 7%, 8%, 9%, 10% and over to guide further ‘management’. This practice does not hold up to scrutiny in terms of lactation physiology, protecting babies, supporting breastfeeding or primary research evidence and yet it continues – perhaps because of how well it fits in to the above schemas of quantitative yields and numerical reassurances. Worryingly, this approach may offer false reassurance.
So in my ethnographic study of Lactation Consultant practice, I found that women saw LCs for a variety of breastfeeding ‘problems’. Very often these problems were associated with a disconnection between mother and baby and very often these problems could be traced back to earlier breastfeeding support approaches when in hospital for postnatal care.
Women had generally experienced the care offered in the postnatal environments described by both Dykes and Burns above. The focus had been on ‘getting breastfeeding right’ with taught positions, expressing and very often this approach seemed to result in more entrenched breastfeeding ‘problems’ when the woman’s body did not meet the required standards.
These problems were then countered with breastfeeding ‘plans’ that were centred on disembodying and busy practices of expressing (!), timing of feeds and focusing on milk volumes and weight gain as signs of success. In the process of attempting to solve problems these strategies tended to create new ones in terms of women feeling exhausted and unhappy and disconnected from their baby and breastfeeding being a negative experience.
LCs were observed to spend a great deal of their time in practice reconnecting mothers and babies with each other – physically, emotionally and with a return to relationality through breastfeeding.
So what do we do with all of this?
We need to do better in our postnatal care for breastfeeding women. We need to centre the mother-baby relationship when we support women who are learning to breastfeed and see both women and their babies as capable and ready to breastfeed. The mother-baby dyad are a unit who are built to relate with one another and breastfeeding is one expression of this.
Breastfeeding is the beginning facilitator of this extraordinary, lifelong relationship.
Our postnatal care environments must be relational environments – which means that anything that interferes with the mother -baby relationship must justify its place there or else be removed.
Are we too busy to provide relational care for mothers and babies? The question has to be asked: “what are we too busy doing?”
Many will have seen the recent hoohaa about the actions of the USA’s Department of Health and Human Services at a recent World Health Assembly meeting in Europe.
Ecuador introduced a resolution that was far from earth shattering or even controversial BUT …. The US were keen to amend it in order to soften messages about the protection, promotion and support of breastfeeding and to block measures to restrict the inappropriate promotion of foods for infant and young children- the kind of products that impact adversely on breastfeeding.
It is an open secret that the US has not been a big supporter of global approaches to breastfeeding advocacy. In 1981 when the WHO Code of Marketing of Breastmilk Substitutes was passed, the US vote was the ONE and ONLY nation to vote against it.
Dr Jen Thomas posted an informative piece on the US history in this regard here
In our work with the Australian WBTi assessment we were able to examine the Australian government’s commitment to upholding the WHO Code.
Australia scored 1.5/10 on this Indicator.
Our piece on the topic was published yesterday for health media organisation CROAKEY (1st degree relative of the iconic CRIKEY). It is here for your interest.
In it we explain the current Australian system for regulation of the infant formula industry and how this falls desperately short of best practice.
If you are a breastfeeding advocate you might already be aware of APMAIF and the MAIF agreement. For many of us it has been a point of frustration that marketing of infant formula has remained rampant in Australia despite all the whoops and hollers about how much WE LOVE BREASTFEEDING.
There has also been little sense of how things could be changed.
The WBTi process gives us direction for how change might occur. It certainly lets us know what the gold standard is for breastfeeding protection:
Key questions: Is the International Code of Marketing of Breastmilk Substitutes and subsequent WHA resolution in effect and implemented? Has any new action been taken to give effect to the provisions of the Code?
Background:
The “Innocenti Declaration” calls for all governments to take action to implement all the articles of the International Code of Marketing of Breastmilk Substitutes and the subsequent World Health Assembly resolutions.
The aim of the Code is to contribute to the provision of safe and adequate nutrition for infants, by the protection and promotion of breastfeeding, and by ensuring the proper use of breastmilk substitutes, when these are necessary, on the basis of adequate information and through appropriate marketing and distribution.
Nations are supposed to enact legislation as a follow-up to the International Code. Several relevant subsequent World Health Assembly resolutions, which strengthen the International Code have been adopted since then and have the same status as the Code and should also be considered. The Global Strategy for infant and young child feeding calls for heightened action on this target. According to WHO 162 out of 191 Member States have taken action to give effect to it but the ICDC’s report brings out the fact that only 32 countrieshave so far brought national legislation that fully covers the Code.
A report by WHO (2013) “Country implementation of the international code of marketing of breastmilk substitutes: status report 2011″ has also highlighted dismal status of the global implementation of the International Code.
The Code has been reaffirmed by the World Health Assembly several times while undertaking resolutions regarding various issues related with infant and young child nutrition.
So proud of the work we have done on this. Australia’s commitment to optimising the health and well-being of women and children can be formalised by starting work now via the National Breastfeeding Strategy public consultation process.
We call on federal, state, territory and local governments to provide leadership that ensures the protection and fulfilment of the rights of women to access information and optimal support for breastfeeding.
The WBTi assessment tool was designed by the International Baby Food Action Network (IBFAN) for countries to use to benchmark and improve policies and programs that protect, promote and support the right of women and children breastfeed. The tool scores countries based on the recommendations included in the 2003 Global Strategy for Infant and Young Child Feeding.
I spoke at a seminar this week organised by La Trobe University’s centre for Health, Law and Society. Examining reproductive loss from legal, social and political perspectives it was attended by about 20 people from varying backgrounds – law, psychology, activism, anthropology, peer support and midwifery. I was invited to share a midwife’s perspective on bereavement care.
Only one of the hardest presentations I’ve ever written …
August Sander’s People of the 20th Century
The role of the midwife in bereavement care.
Tensions in care.
Future ideas…
This list is supposed to be a template for my ramblings – hopefully it will fool you into thinking that this thing has a structure. As in my research currently, my ideas are undisciplined and messy at the moment and that is how you will hear them today.
Hopefully they will be helpful in at least starting discussion or stimulating questions.
Thanks so much for asking me to be involved today. There is much about midwifery that I feel strongly about and bereavement care is no exception.
Thanks for naming the taboo and breaking the taboo with today’s seminar.
Midwifery 101.
Midwives care for women through the continuum of pregnancy, labour, birth and the post partum period. In the maternity system in Australia midwives are present at every birth of a baby, regardless of the type of birth.
Normal births are of course what we are trained for, but we also stay “with woman” regardless of the birth outcome.
We practice “watchful waiting” and we work as much as possible with physiological events as they unfold.
Although most of us have trained in pretty heavily medicalised systems we are believers in pregnancy and birth as part of normal life – these are for us “normal physiological events”. Sometimes we have to work hard to “keep things normal” too – when events are threatening to spill over the boundaries into what is considered “abnormal” or “non-reassuring” or beyond the parameters of the particular institution we are working for – when there is a risk of intervention and what we refer to as the “cascade of intervention” as more and more interventions follow. These actions can be justified by the need to minimise risk, increase surveillance, expedite labour or birth or relieve the suffering of the birthing mother.
We seem unscientific in our mistrust of medical intervention, even unrealistic or unnecessarily reckless in our belief in the power of women’s bodies. Midwives live with the tension to varying extents.
Sometimes, too, we have to work in highly technical and medicalised situations with women who have serious medical conditions or who developed pregnancy or birth related complications.
And of course, sometimes we have to help women labour and give birth to their dead babies or to babies with serious or life-threatening abnormalities or who simply come too soon.
“With woman” is the meaning of “midwife” and we do this in all these situations.
We define ourselves as a constant support for women in what can be a vulnerable time and when they may be seen by many different caregivers.
Providing bereavement care is a privilege for midwives.
Of course, being with women and families when their healthy, live baby is born is one of the biggest highs ever.
It is a glimpse into the universe. A glimpse that you might have three or four times in one shift on a busy night… or see three times in 45 minutes. Nonetheless a sacred moment.
In the balance of the universe, then, midwives understand the need for sensitive and supportive care for families deprived of that experience. So that these parents might too have a sacred moment.
Midwives recognise that this baby was born into love and a family and that this baby needs to be remembered and mourned, and the baby’s parents supported and cared for.
How things have changed in a generation or two – student midwives weren’t permitted to care for bereaved families when I trained and there was an unspoken rule that only “experienced” midwives could really do the work.
Unfortunately that meant that the work fell to a small number of midwives who did mostly bereavement care. There were no formal support systems for them – it also was traditional for them to be in charge of delivery suite at the same time that they were providing the care. Other midwives took on the rest of the workload and their care of bereaved families was intermittent rather than intensive.
It did also ensure some continuity of caregiver. It also in some way reflected the importance of this work by having the midwives with the most expertise and experience providing the care.
What is the nature of bereavement care?
There is little definition of what is required of midwives in their role. It is an extension of their care role for women with live babies I guess. With some pretty fundamental differences. But it is not articulated. In the policy and procedure I read from the hospital the information was heavily procedural.
I would say that this is a significant tension in bereavement care: between providing relational, sensitive and personalised care and meeting procedural obligations.
There are a mountain of forms to fill out that are specific to bereavement care. They concern information for perinatal statistics, consent [or non-consent] for post-mortem, information for funeral directors, follow up appointments and so on. There are also the round of people who are usually involved in postnatal care that need to be informed about the nature of the birth… maternal and child health nurses will make a phone call if able… home visits from hospital midwives are offered. The woman’s GP will receive a delivery summary including the birth outcome.
These forms generate a significant amount of anxiety for midwives, for while they are part of a “team” of carers – the midwife co-ordinates the care. And this paperwork is distinctive for bereavement, so it is often unfamiliar. It also assumes a continuity for midwives – a “primary” midwife signs the care map and takes responsibility. And yet it’s rare that someone will take care of the woman throughout her hospital stay, much less beyond this.
I want to talk more about the nature of bereavement care. What is it that makes it a privilege to be involved in.
I have been reading about embodied care and the work of French embodiment theorist, Maurice Merleau-Ponty.
How we humans are by nature social beings.
How there is an intertwining of knowledge and relationships. How the “I care” and the “cared for” share a reciprocity where both receive benefit. This reminds me of the intensity of the midwife-woman relationship. This is a relationship of embodied care – in contrast to much of the disembodiment we experience in our lives in the late post modern world. The midwife makes use of her connection to her own knowledge of her body – not always, statable, rational knowledge but rather pre-conscious or felt knowledge to care for the woman. By nature, this embodied knowledge is reciprocal – the midwife gains as much as she gives in her carer’s role. Unfortunately this kind of relationship is often discouraged in institutional settings where distance between cared for and the carer is encouraged by its systems and culture. Ostensibly this is to control the anxiety of the caregiver as per Isabel Menzies Lyth’s work on nurses. This is possibly amplified by feelings of guilt and blame in the case of a bereaved family.
Where in fact these care relationships are what make the job worthwhile.
So back to talking about the nuts and bolts of bereavement care. In my workplace, as well as the midwives providing care, there is also a bereavement worker that is chosen by the woman – more religious or not, or maybe a genetic counsellor that a family has come to know over the pregnancy.
These carers work 9 to 5 but are also available on call to some extent.
Their responsibilities are to do with “intended arrangements” – they meet the family and discuss funeral or memorial service arrangements and follow up and refer to other services as needed.
The worker usually meets the woman and family once after the baby is birthed. There is scope for further contact via follow up phone calls in the coming weeks.
Interestingly, midwives are invisible in the hospital’s policy and procedure. They are barely mentioned. There is some expectation they will fulfil the tasks of the bereavement worker if the birth occurs after hours.
As a clinician I was often confused by what the role of the bereavement worker was. They sometimes had more time to spend with families than you could so that was welcomed… and they had expertise about arrangements for burial and memorial services and so on, but looking at things now I wonder about the wisdom of introducing yet another person to the experience. Now from a distance this looks like unnecessary fragmentation of care, but it would be great to hear how families respond to this. They may find it very helpful.
This is clearly an experience where relational care is clearly important… where midwives are practising their craft of being “with woman” for very vulnerable people.
So what might be a better way to think about the midwife’s role in bereavement?
Maybe it’s about more honouring of the mother-midwife relationship. A commitment to continuity of caregiver is associated with better outcomes in midwifery care as proven by randomised controlled trials.
I often felt a sense of non-closure after caring for these families. I’m not sure whether that has to do with the nature of the care itself or perhaps of the enormity of the task. Possibly it is connected to being involved in an “unexpected outcome” –guilt perhaps?
We are conditioned to sharing happy events with families.
How can we feel satisfied with our care when the outcome is devastating?
Families too, can have difficulty leaving the hospital – often without their baby. In some ways they fall into a hole or a chasm after discharge – ideally into the arms of a supportive family but not always. Because of the taboo conversations with others are difficult – there is much to be negotiated.
There is always medical follow-up after post mortem at an outpatient appointment – midwives might like the option of being involved in this. Maybe this wouldn’t provide closure… but a feeling of being cared for? Both for mother and midwife?
A familiar face? A bridge between the medical and the maternal?
Someone who was there and knows the intricate details of the “case” as well as how people were during the experience.
A chance to talk about life since then.
A baby death in whatever form is taboo. What are the impacts for caregivers? It is often an unspoken experience for midwives – not even to be shared with our significant others. What impact on our own pregnancies and birth experiences? We count the weeks of viability to ourselves, we hold a hidden knowledge that even a baby at 38 weeks might die mysteriously. It would be great to hear these experiences.
Given how much has changed in a few generations, might we allow for more stories to be told? – beyond the front page hysterics of “preventable baby deaths”?
And the public airing of women’s stories of lost babies in situations they couldn’t understand…
I have argued for more recognition of the midwife’s role in bereavement care. We are the ones standing next to the woman through it all. Systems can change to allow for relationships to flow between bodies.
People seek relationships in times of trauma.
Midwives would need support to do this work – formal and structural and dedicated.
I had a formative experience with two friends.
Their first baby came “too soon” at 22 weeks. They brought her home with them soon after she was born and I was invited around to visit.
I learnt so much from them. I stayed for a few hours and we talked through the experience of the past few days. They had brought their baby home and I cuddled her and we took photos and talked to her and cried a lot together.
I attended a funeral ceremony with their friends and family a few days later. They are both health professionals and they were determined to acknowledge the birth of this first child of theirs.
They brought others into their circle of care.
They had more children after this one – but she is always part of their family.
There is no question that it was a privilege for me to be involved in the events surrounding her death – and birth, and then in seeing how the experience fitted into the rest of their life.
Women at the hospital where I work are scheduled to receive breastfeeding information at their 26 week check-up visit.
It’s my favourite visit even though it can be tricky getting through all the information required to be imparted during this time. I make up for this by talking fast!
The midwives have a checklist we have to work through (another of my not-favourite thing) but it covers the essentials – benefits of breastfeeding to mums and babies – (don’t forget dads! They can get better sleeps for years if things pan out…) rooming-in policy, non-giving of formula to babies being breastfed without a medical indication, non-use of dummies in hospital, resources for support after leaving hospital and so on…
We are meant to start by asking how women are “choosing” to feed their babies. Seriously, about 99.9% of women we see – from very varied communities and backgrounds want to breastfeed. Sometimes I would breach protocol and ask “how are you going to breastfeed your baby?”
A Norwegian-born woman in my ABA group told me how the question astounded her: “in Norway no-one would ask – there is only one way to feed a baby!”
Then we are meant to chat about the benefits of breastfeeding. From my days of teaching breastfeeding education classes in the community I know that everyone (and their dog)knows the benefits of breastfeeding (especially the dog, right?). “Breast is best” is a health message breathed in like air. It doesn’t keep women breastfeeding, but it probably starts them thinking that its something they might like to do.
I skip this info – “you will be well aware of the health benefits of breastfeeding to you and your baby”. Lots of nodding…
Then I tell a story to them. It’s the story of what happens when their baby is born and they start to breastfeed.
My plan is to normalise the experience and to be realistic about what the first days with a newborn are like. Prospective parents are unlikely to hear about this from other people… in fact the families I look after post-natally seem to generally be overwhelmed by their experience in the first days. It is such a short and stunning period of time for new parents that it is quickly forgotten. But this moment is an opportunity to consider what a baby’s first days are like – physiologically, and then to relate this to the experience of breastfeeding in the early days. which we know as midwives is a cruel, intense but life-changing time for parents and their babies.
Here are some things I say:
After your baby is born he or she will be handed directly to you and placed skin to skin with you. Your baby will be dried off while lying on you and be closely observed in the important first minutes as she breathes air into her lungs for the first time.
We know that skin-to-skin is not just a nice thing to do, but actually helps your baby transition to life beyond the placenta. Babies in skin-to-skin contact with their mothers stabilise their breathing and their heart rate and their temperature better. And something else happens too…. babies start to look for the breast. Babies will literally crawl towards their mothers nipple, attach and feed if left undisturbed after birth. I get to see this all the time in my job.
If you want to see babies do this too you can search “breastcrawl” on YouTube and see lots of newborn self-attaching.
We like newborns to self attach if they can because when they do it themselves, they do it properly. Not only that, when they get it right the first time – they go on to do it right time after time from then on.
I talk then about how that first feed should take an hour or even two hours. And about how babies are awake and alert for the first hours after birth – so that they can breastfeed well. I also mention how oxytocin in the mother’s circulation is making more colostrum available to the baby in that first feed than it will over the next 24 hours – oh, and also how the breastfeed will help to contract the woman’s uterus during this time – to deliver the placenta and limit her blood loss.
Nothing beats the faces of parents-to-be at 26 weeks listening to all this – I think this is often the first time they have really thought about the nuts and bolts of this almighty adventure they’re embarking on! And then we talk about how babies usually have a giant sleep after this – maybe for six hours. More nodding.
How often do new babies need feeding? More is more in the colostrum world – small amounts frequently is key. Thick gooey colostrum – more medicine than milk at this stage.
Every feed is also a good learning time for mum and bub. Also extraordinarily comforting and reassuring for a new baby in a giant world of weirdness.
Sleep? I hear you ask… mmmm – not so much. Here’s what the postnatal ward is like on any given night – it’s party time!
Newborn babies are more like teenagers than any other group I can think of. They behave like angels all day and evening through visiting hours and then at about ten o’clock they all wake up and want to feed. Not once, not twice, but continuously – until about 4am. Then by 6am they are all fast asleep. When the morning shift starts at 7am they find a ward full of sleeping mothers and babies. It’s natural.
Mornings are very settled times. Then the feeding frenzy begins again after lunch…or at least we’re all trying to get babies to feed again in search of that holy grail – more sleep overnight. Good luck.
Sounds great doesn’t it? Everytime your baby wriggles is a good time to try a feed. Don’t wait for your baby to cry.
Expect lots of sticky black meconium nappies in the first few days. Not much wee until your baby’s digestive system and kidneys start to fire up – and the colostrum increases in volume (that’s happening all the time by the way, as you keep feeding). Black tar poo is replaced by darling green numbers and then mustardy slops that smell like fresh mown grass! yum! Now watch out for the wee fountain on the change mat. Not just for boys!
Now your baby’s tummy is expanding as the volume of feeds increases. And then…..your milk comes in and Everything Changes.
But I tell them not to worry about all that just yet.
The most important thing that I mention is that through all this time there will me midwives like me supporting them.
We are mostly friendly dragons who love babies.
We midwives know lots and lots of things about lots of different babies – but probably very little about your baby. In eight hours you will know more about your baby than us. We can give you info about some principles and tick off important tasks like teaching you to bathe the critter (after 48 hours) or showing you the phone number for the ABA breastfeeding helpline or teaching you “what to do when you get home” (my script for that one still needs work). So just ask us. The questions will start to really flow when we visit you at home in the first week.
A lot of the time we do a version of cheering you on from the sidelines. Cause it’s hard and tiring and being in hospital is mostly crap. But soon you will go home and your milk will come in … and Everything Changes. So now you know.
This is the first of several blog posts I want to write reflecting on the inquest into the case of a woman who died in hospital after giving birth at home in Victoria, Australia.
In part 1 I discuss the context in which homebirth and homebirth midwives are regarded in Australia and allude to some of the challenges faced by them in carrying out their work including attitudes toward homebirth, concepts of risk and communicating with mainstream services.
I have worked as a midwife in Australia for the last 20 years and I was interested to know more about a recent case where a woman had died in hospital after giving birth at home. I attended one day of the initial coroner’s enquiry and then another day of the inquest.
I admit that I really wanted to know whether this would be a case of putting homebirth on trial and/or independent midwifery. Does that sound cynical? Let me explain the context.
Fewer than 2% of births in Australia are planned homebirths. Other countries are more accepting of the model – it is the default model of care for women with normal pregnancies in The Netherlands. In the UK there is official acknowledgement that homebirth is a safe and reasonable option for many women and that it also serves to (pragmatically) relieve some burden on an already overcrowded hospital system. Both of these countries have an enduring culture of midwifery care for pregnancy and childbirth. This is not a coincidence.
But if you think that homebirth in Australia is only a marginal dreadlocks- tie-dye- hippyfest please note that there are a dozen or so publicly funded homebirth programs currently operating in Australia, many connected with maternity hospitals.
Despite this, generally speaking, the mainstream maternity care system has little respect for alternatives.
A friend of mine, planning a homebirth, presented at a large tertiary maternity teaching hospital with some elevated blood pressure late in her pregnancy – as suggested by her independent midwife. The doctor who she saw in the emergency department asked her first up why she was trying to have a home birth – didn’t she care about the health of her baby?
So that’s just one lousy case, but it’s what I have found to be a pretty standard (and disappointing) reflection of the general attitude to homebirth amongst medical (and many midwifery) staff in the hospital system.
I say disappointing because the choice a woman makes about her care in pregnancy and birth should surely be respected.
Where there is no respect for this choice, women who have planned to birth at home and then unexpectedly need hospital care may indeed face a hostile audience (see above).
We live in a world arranged around risk management – in life as in maternity care. In this coroner’s case there was considerable discussion of the risk status of the woman in question.
In Australia some women are considered to be of sufficiently low risk to “qualify” for a homebirth in the public system or with an independent midwife. Others don’t make the cut and are assigned to more medicalised care. Pre-existing medical issues or a chequered obstetric history place them at “high” or “higher” risk.
The social science discussion around our modern obsession with risk acknowledges the rationalist and neoliberal influence on our thinking – where things are quantifiable they are containable and manageable.
Right…?
I pity the person who claims to be able to contain and manage that behemoth we know as childbirth. Still, we try.
In an ideal world, independent midwives look after low risk women as per professional guidelines.
Independent midwives, however, are often sought as carers by women who have been traumatised by the mainstream maternity care system or healthcare system in general (or even other institutions). These women quite understandably seek the woman-centred, continuity of caregiver, non-interventionist philosophy that defines homebirth midwifery – regardless, or indeed perhaps because of, their “risk status”. Independent midwives may face the very difficult decision of whether to continue to care for a woman beyond her scope of care or risk the woman deciding to birth on her own without care.
Paradoxically, women who have the most challenges in their pregnancies or birth – which may or may not translate as their “risk level” are also known to benefit from a relational model of care involving continuity of caregiver… just as their low-risk peers do.
Which is just the kind of model that an independent midwife offers. And yet we know that independent midwives may have difficulty communicating and collaborating with more mainstream maternity services because of attitudinal barriers related to homebirth.
Independent midwives who care for those women least likely to engage with mainstream maternity models need to be valued by that system and offered every chance available to provide the care that this woman and her family need. This would involve mainstream services being open to supporting rather than condemning women and midwives working in this model of care.
Every pregnant and birthing woman needs care not only in relation to her risk status but her individual needs.
This is a piece I wrote about a local hospital in the outer suburbs of Melbourne, Victoria, Australia. I know it’s a sensitive topic to many of my colleagues and friends, but I’m writing it because I’m tired of the way women have been used in the media coverage of this issue and the way staff at this hospital (and others) have been vilified.
The stories that have unfurled over the past four months regarding Bacchus Marsh Hospital’s maternity services have certainly been concerning. More than expected numbers of unexplained baby deaths were the trigger for the hospital’s board to be sacked and for the Health Minister to announce concerns about the hospital’s obstetric practices and standards of care. But the media’s handling of the issue has been focussed on blame and retribution and an almost voyeuristic preoccupation with personal stories of baby deaths and maternal wound infections. There also seems to have been little concern for the reputation of local health services in general.
There have been numerous television and print media stories about the alleged “horrors” of Bacchus Marsh hospital’s obstetric services. Even a newspaper piece written by one of the litigation lawyers.
Many of the stories in these reports have come from women whose babies have been stillborn or who have themselves personally suffered infections or complications post-birth at the hospital. Very upsetting stories. Of an often very personal nature. Life-changing events for these women and their families.
These stories have been used by the media to argue that particular doctors at the hospital are unfit to practice.
It is not the media’s responsibility to judge the competency of medical staff at this or any other health service and their use of women’s very personal experiences to this end does not honour these mothers or the memory of their babies.
Instead, the stories have been used to create emotional leverage bordering on hysteria, all the while touted as “giving mothers a voice”. Meanwhile these women have shared their heart-wrenching stories with the world – but to what end?
Many media segments have similarly implied that every baby death at every Victorian hospital is the direct result of medical mismanagement. Sadly, there are babies born every single day in Victoria who never take a breath. The perinatal mortality rate for Victoria in 2011 was 10 in 1,000 births. The reasons for these deaths are often a complex combination of macro structural issues and individual management – important factors that need ongoing close and careful examination by people with appropriate experience and training such as the Consultative Council on Obstetric and Paediatric Mortality and Morbidity (CCOPMM).
One newspaper article last year listed the “likelihood” of baby deaths in specific Victorian hospitals. Interesting stats but what do they really mean and to what end?
These are local community hospitals that people rely on for their healthcare.
There is rarely an alternative service for these people to choose. What do locals do when they lose trust in their neighbourhood health service? And what exactly does it mean that babies are 80% more likely to die at your local hospital? There was no attempt to contextualise these statistics.
At what point does the media take responsibility for the impact this kind of reporting has on undermining local trust in health services?
Bacchus Marsh is a local hospital. It has been a great option for women in the area with normal pregnancies to receive maternity care and to birth close to home. The number of women booking to have their babies there increased exponentially over the last ten years. Despite departmental concerns, the hospital is still open for business and presumably it’s staff are trying to somehow rebuild some of that local trust they gained as the hospital’s birth rate grew and grew over the last ten years.
From all this it seems that there are really two key issues that need addressing in this situation:
1. the professional regulation of medical and allied health practitioners is currently the responsibility of AHPRA, and its actions are being called into question, especially regarding delays into investigations of practice. No doubt this is a complex issue related to process and structure.
2.The other issue involves systems of management and leadership for hospitals in Victoria to ensure safe practice and good health outcomes in these services. Not exactly a racy media hook, but good structures can improve accountability and importantly, help to ensure that people trust their health services to provide safe care for them.
So why not focus on investigating these issues rather than fishing around for allegedly shonky operators who are unlikely to be solely responsible for large numbers of baby deaths, or bringing down the names of local health services who may or may not have practice issues related to their statistics?
If a health service is truly dangerous it should be shut down – no question.
But my heart is with those dedicated health professionals still working at Bacchus Marsh – battling every day the fallout from media stories denigrating their work.
It’s also with the women and families who have shared their stories of heartbreak publicly. Maybe their experiences will help us see the human side of the statistics.
JennytheM shares her sense of urgency around the need for midwives (in the UK but also elsewhere when forces prevent us doing the work we need to do) to stand tall like our sisters before us.
The Suffragette film has so many parellels in my life as a midwife and also as a single mother that I just have to write about it
As a midwife I see the strength and courage of women on a daily basis – I also see vulnerability , sadness , wisdom and grief .
These emotions and traits are also part of me and every midwife and must be recognised and valued
Until I “found” myself through social media I was almost lost and felt that I’d never fit in – through the power of twitter I have found my place and I’ve gained #courageButter . I have connected with brilliant inspiring midwives, future midwives, doulas, obstetricians and several others who are not necessarily birth workers but who embrace the fact that birth is part of our psyche .
We are all born therefore it is crucial that any birth…
I have a friend who is pregnant with her first baby.
In the last few weeks I have been thinking about what books would be helpful for her to read in preparation for motherhood.
So I read a few.
To be honest there were few such books around that I thought would be helpful at all. My first child was born 16 years ago, but I have been working and thinking (!) as a midwife since then, and there seem to have been few bright moments in the Transition to Motherhood genre.
The books I have just read were a mixed bunch.
I think I can envisage the editorial meetings – “maybe a few more funny stories about the [INSERT: ridiculous health professional] who tried to help you to breastfeed/get your baby to sleep/push your baby out of your vagina/join a parents group”….never mind how hard people may have worked to help you.
Many of the writers who share their stories of becoming a mother oscillate between themes of “I’m special because this is what happened to me” and “my experience is an archetype of what becoming a mother is”.
Most worrying is the theme of belittling health professionals and structured support systems as being “not for them”.
“I’m not much of a joiner”.
What does that even mean?
Several writers talked about their reluctance to join a new parents group where the only thing members had in common was the lottery of giving birth. What was the reason for their reluctance?
New parents groups are a phenomenon of living in the Maternal and Child Health system of the People’s Republic of Victoria, and are also present in other states of Australia.
Maternal and Child Health Nurses, who work for local councils, organise groups for parents to meet when their babies are between 6 weeks and 3 months old. Usually there are structured meetings for 6 weeks or so at the Centre. After that groups may continue to meet informally at members’ homes or playgrounds or community centres or playgroups.
Research about mothers and parents and playgroups indicates the strong social role that such groups play in a context where isolation is more prevalent – especially for mothers and children. These groups have also been found to provide, at the basic level, an opportunity for mothers and families to receive care – different to other modes such as clinic or home visits.
What worries me is that prospective mothers reading these books get the idea that these groups are daggy or a waste of time – especially if they aspire to be the uber cool inner city types that these authors often are.
I also worry that these attitudes add to the ongoing narrative of: “we only like to hang out with people who are like us”.
Isn’t this the narrative of an oppressed group?
My own involvement with the Australian Breastfeeding Association came about at least partly in order to deal with general societal ambivalence about breastfeeding. ABA meetings were a haven where you could breastfeed your older toddler with freedom. [*sorry freaked-out new mums].
Not that my mother’s group were anti-breastfeeding. But I guess I had a bigger aspiration to be involved in community-based breastfeeding support. The added benefit of these meetings was that there were women with babies and children of all different ages attending. Having a child who didn’t walk until he was almost two and breastfed for several years longer than that was definitely less of a drama at ABA meetings.
Grassroots groups like mother’s groups or playgroups are inherently subversive. I wanted to be a part of that – an autonomous collective of sleep-deprived nobodies – no-one could control us (not even the maternal and child health nurse once we busted out of her centre). No-one was interested in us except us. But we were building the sorts of networks that help you when you have another baby or go through IVF or you need a job locally or need someone to have a cup of tea with when these kids finally and suddenly have their first day at school.
Why wouldn’t you want to be a part of that?
Not a joiner? That’s ok. But your child will need other kids at some point – they can’t play with you in the café for ever.
Soo Downe and Sheena Byrom are midwives from the UK with long and illustrious clinical careers in midwifery and also many midwifery research projects and publications to their names.
This year they published an edited collection of brief, sharply edited chapters written by 50 (count ’em) different authors.
The topic that the book deals with is the need for maternity services to be based on a philosophy of kindness and compassion: [back cover blurb]
For many years there has been growing concern about the culture of fear that is penetrating maternity services throughout the world, and that the fear felt by maternity care workers is directly and indirectly being transferred to the women and families they serve.
The consequences of fear include increased risk of defensive practice, where the childbearing woman and her family become potential enemies to those providing her care. In addition, the prevailing risk management and ‘tick box’ culture in maternity services encourages maternity workers to give priority to the records instead of the woman. These factors contribute to the dissatisfaction felt by those using and providing maternity services. There is however increasing evidence that kindness, compassion and mutual respect improve efficiency, effectiveness, experience and staff morale within healthcare settings.
The book is divided into three sections:
1. Stories and perspectives from maternity care.
2. Principles and theories.
3. Making it happen: solutions from around the world.
This is an action manual for creating change.
These are issues that are not only for the UK to be concerned with – in Australia we have important problems to address with regard to how maternity care is provided, how women are respected within particular models of care and, of course, with regard to rising caesarean section rates and the consequences of this.
The chapters in the book are written by people as diverse as…
Kirsten Uvnäs Moberg: a medical doctor and author of two books on the physiology of oxytocin. Her take on the impact of intervention on the action of oxytocin should make us reconsider the “safety” of many interventions which effectively block the action of the hormone.
Alison Barrett: an obstetrician who practises in New Zealand, and talks about how motherhood is not valued in western culture, “which is a nice way of saying that our culture (still) hates women” (page 63). She describes how every woman in the maternity system deserves the Best of Care. Every woman. She invites us to examine the barriers in our own minds that prevent us from providing this.
Milli Hill: is a writer and campaigner and author of a book on water birth. She is the founder of the Positive Birth Movement – a grassroots organisation designed to promote discussion amongst women about positive birth. It emerged as an antidote to the widespread cultural fear of childbirth. As she says: “women in the PBM network consistently report that being treated and spoken to with kindness and respect is at the heart of a positive birth experience” (page 189).
Anna Byrom: is a midwifery lecturer who has used drama through Progress Theatre to explore issues through critical reflection and discussion and debate in maternity and general healthcare services. The chapter, co-written with Adele Stanley, Gemma Boyd and Kirsten Baker, outlines how their methods have enabled understanding of different participants’ experiences in healthcare settings as well as personal development – with a view to providing compassionate care.
Mavis Kirkham: is a midwifery researcher who has written about and researched midwifery for 40 years. Her work has often focussed on the context of midwifery work and what kind of care this produces. Her chapter argues that the NHS maternity care system is a powerful shaper of how midwifery care is delivered. We can’t ignore the impact that a system which oppresses midwives has on the way care is given.
Hannah Dahlen: is an Australian midwife researcher and practising midwife who is a professor of midwifery at Western Sydney University. Her research has covered topics such as episiotomy rates, perineal safety during birth and the impacts of place of birth and antenatal care on birth outcomes. Her chapter in the book (co-authored with Kathryn Gutteridge) looks at how the fear of midwives impacts on the experience of women during pregnancy and birth – how models of care based on risk alone take so much away from the the miracle of the
experience…and also the joy of doing midwives’ work.
Maybe you don’t usually read books about midwifery?
That’s ok.
This is unlike any midwifery text I’ve read – the chapters are readable, understandable, distinctly lacking in researcher or academic jargon, and contain many stories. They are also SHORT, concise and written in such a way that if you want to find out more about a particular person’s work or point of view, you can easily do so by looking at the reference list for each chapter or googling the organisations and publications referred to.
It is also a great way to find out the names of people who are doing interesting and stimulating work in our profession.
The other amazing thing is that at the end of each chapter there are summaries of key messages, and then a list of action points: what you can do – as a midwife.
I’m excited about this book because it has the potential to enliven and excite our profession towards change – a change that is centred on kindness and compassion for the women and families in our care.
The book is available for purchase online (for less than 20 bucks) via Amazon or Book Depository or locally through Capers: http://www.capersbookstore.com.au
jenhock 