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?
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 …
The role of the midwife in bereavement care.
Tensions in care.
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.
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.
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.
An antiquated term, (except among post-modern midwives I would argue!) quickening refers to the time when a pregnant woman first feels her baby move.
I have written previously about Barbara Duden’s descriptions of the embodied knowledge of women in 18th century Germany: The woman beneath the skin.
In another book called Disembodying Womenshe examines how modern pregnancy and childbirth has removed women from their bodily experiences. Her chapter on quickening raises a number of interesting issues.
Throughout history the perception of foetal movements has been the only way for pregnancy to be diagnosed. Well, self-diagnosed. Because it is the pregnant woman and only the pregnant woman who has access to this knowledge.
And so, a woman announced her pregnancy to an audience appropriate to hear the change in her status.
Such personal authority.
As well as being a concept owned by the pregnant woman, quickening was also a legal category: “life” was seen to have begun once the mother felt the baby move within: perhaps as “late” as 23 or 24 weeks for primigravidae or as early as 16 weeks for multigravid women.
In North America and Europe the quickening was directly related to laws surrounding termination of pregnancy: only a woman “quick with child” who aborted could be charged with a felony. This provided the woman with some expert status: no-one but she could confirm the movements and thus the baby’s gestation.
Duden quotes Mohr’s work about the paradoxical situation that arose in the US where the law did not formally recognise the foetus as existing until it quickened:
“the upshot was that American women in 1800 were legally free to attempt to terminate a condition that might turn out to have been a pregnancy until the existence of that pregnancy was incontrovertibility confirmed by the perception of fetal movement “. James Mohr (1978) Abortion in America: the origins and evolution of national policy.
Whatever injustices faced these women in their day to day life, they were at least in charge of their reproductive state by virtue of their own embodied knowledge.
Contesting the worth of this embodied knowledge, nineteenth century laws arose that criminalised abortion – late or early, based on medical authority. The woman effectively disappeared from the argument.
Today our gravid state is early news. A blood test at 41/2 weeks, a wee on a stick a little later, a conversation with our fertility doctor or an ultrasound at 6 weeks. We need to know early because there are things to be attended to.
But the pregnant woman’s perception of her baby’s movements still has some importance in determining the well-being of her baby: we now know that these foetal movements are actually a crucial indicator of foetal well being and adequate placental functioning. Women’s reporting of reduced foetal movements is strongly associated with stillbirth.
In the UK campaigns ask women to “count the kicks” in an effort to reconnect pregnant women with the sensations of their pregnant bodies.
Midwives in clinic in Australia dutifully urge women to attune themselves to the “normal” pattern of duration and frequency their own baby demonstrates in the kicking department. Often we receive puzzled, blank looks in response.
We all struggle because there is little evidence for what is “normal” – even though by god we’ve tried to quantify it.
We also struggle because at almost every turn in pregnancy care we disembody the experience of pregnancy for women.
From pregnancy diagnosis by peeing on a stick rather than observing physical changes, by submitting to “essential” screening of our precious foetus from the middle of the 1st trimester, by ultrasounds that “show us” our baby – a baby we already “know” exists … in all these interventions we say “technology measures your experience of this” – not you.
But please, let us know if baby isn’t moving as much as usual.
When women do report a reduction in foetal movements, there is widespread suspicion: “she’s overly anxious”, “she wants an induction”, “she doesn’t really understand what reduced foetal movements are”…
The overarching subtext is that women cannot really know their own bodies.
The thing is, in terms of baby movements – they are all we have.
As Barbara Duden outlines in Disembodying Women:
“in the course of one generation, technology along with a new discourse has transformed pregnancy into a process to be managed, the expected child into a foetus, the mother into an ecosystem, the unborn into a life, and life into a supreme value”.
I’m reading a lot of research that considers the best ways to prepare and support women to breastfeed.
Truth is, we really don’t know for certain what’s the most effective way to do it.
One theme that seems to be coming through is that thewhat isn’t so much of an issue as the how.
When women are asked about what care was helpful to them, they talk about having their feelings acknowledged and being listened to.
Graffy and Taylor (2005) undertook a randomised controlled trial in the UK to measure the outcomes from a particular model of breastfeeding support. As well as this, they asked the women in the trial about what they thought constituted “Good Breastfeeding Support”.
The authors summarised it in 5 points:
1. women wanted good information about the benefits of breastfeeding. This was so they could defend their decision to breastfeed when they were questioned (as they expected to be) by their family and friends (!).*
2. women, as I mentioned above, wanted their feelings acknowledged and wanted to feel listened to.
3. women wanted practical tips for breastfeeding such as different positions for feeding.
4. they also wanted reassurance and encouragement to breastfeed.
5. Provision of resources for what to do if they were having trouble – someone to call or make contact with.
Not a bad list.
I would defy any midwife to not know how to provide the elements these women were after.
One of the big points here is that women aren’t expecting a huge amount from their caregivers. Mainly time, patience, a listening ear and some encouragement. You don’t need to solve all their problems….but hey, preventing some would be excellent.
As midwives, we can do this by helping them get to know their new baby – to read the baby’s cues, to offer the breast when the baby is quietly alert, to hold the baby close any time.
To believe them when they say they have tried to feed.
To stay with them when they are going to try.
You don’t need all the answers – you will have seen enough babies to know the range of what is normal – and be amazed by the immense variation in this!
Something I tried to mention to women in clinic when we were talking about breastfeeding at the 26 week visit (probably should have had a chat about it at every single visit…) was: “as midwives we know a lot about lots of different babies …but not so much specifically about yours – you will very quickly become the expert on your baby – you can use us midwives to help along the way with figuring it all out”.
My experience as a volunteer breastfeeding counsellor and then training to be a lactation consultant helped me realise there are more important things than “knowing all the answers” to breastfeeding problems when we are supporting women to breastfeed.
So much more is about walking beside them on the journey.
*just by the by…I think this issue needs unpacking (and highlighting) a bit more. Never mind criticism of the health message “breast is best” – when women are being judged on their decision to breastfeedby their own families!
Aaah…listicles. The favourite friend of the blogger. I’ve got some thoughts to share about midwives. Thought you oughta know.
1. Midwives are trained to care for the “normal” in pregnancy and childbirth.
“Normal”, however, is a setting on the washing machine. Midwives actually have the skills to provide care for ALL women during pregnancy and childbirth. Sometimes this care is in collaboration with a qualified or trainee obstetrician, and sometimes other medical specialists too. Midwives can stay focused on the woman’s transition to motherhood – psychologically and emotionally, while others provide their expertise.
2. Midwives like looking after “normal” pregnancy and birth.
Often the midwife’s work is to keep pregnancy and birth normal or even take steps to bring it back to normal when things go astray. Sometimes this can be bloody hard work, especially when other forces seem to be pulling in different directions.
3. Midwives take postnatal care seriously.
It’s neither “dramatic nor technologic” but it matters. To mothers, to families and to our world. And midwives do it. No other group of professionals have the expertise or passion that midwives have to provide this care. But women have low levels of satisfaction with their postnatal care, compared to other episodes of maternity care. We don’t know why…is it the care or is it something else – like the questions we are asking…or comparing it with other episodes of maternity care?
4. Wherever midwives are recognised care providers in the world, normal birth is advocated for.
http://midwives4all.org promotes the evidence that proves midwifery care assists in reducing maternal mortality and morbidity rates and neonatal mortality rates. All women deserve midwifery care.
5. The world needs more midwives doing research into midwifery.
There is very little encouragement for midwives to do postgraduate study and learn how to do research. Consequently the research focus in many maternity hospitals is determined by medical staff. Midwives need to be equipped to do their own research – that way they can investigate the issues that matter to them as a profession and find solutions to clinical problems that matter. Dollars and pathways are needed.
6. Midwives are revolutionary by nature.
Even when they work in institutions, midwives know they do their best work when then follow the needs of the women they care for. This means they often have to defy the needs of the institution in which they work. When midwives work outside of institutions, they are criticised for doing ‘risky’ work.
7. Midwives are often oppressed by the structures they work in.
This can be especially problematic when the policies of that institution prevent them from providing the care for women that is needed and wanted. This makes them seem rebellious at times, and difficult to manage. Sometimes they go “underground” in order to do their job.
8. Midwives gain immense satisfaction from the work they do.
This means they often put up with a lot of criticism and confrontation to keep doing their job.
9. The work of midwives has consistently been undermined by others with vested interests in their sphere of care.
These interests are invariably about the amount of money to be made by providing alternative care to that of midwives, not in providing safer or better care for women. When history is read from the point of view of hospitals and the public health service they have provided, it may appear that they were trying to protect the interests of women. Complication rates were initially very high in these institutions, however, and were patronised by women who were too poor to even give birth at home.
10. Midwives have a significant role to play in public health.
Midwives provide primary health care at a significant time in a woman’s life. They have the potential (often realised) to encourage significant health behaviour change in a woman and her family during this time (think: smoking, nutritional choices, illicit drug use, general exercise and activity levels). Midwives primarily enact these changes through their care relationships with women.