The Roar Behind the Silence: book review

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.
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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

Do yourself a favour.

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Quickening.

Are you familiar with the term?

Quickening.

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 Women she 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”.

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The Woman Beneath the Skin. How do we know our bodies?

f5636b29c20358604ed05357c3bee8aaBarbara Duden is a German historian who has studied the work of Dr Johann Storch –  a physician working in a German town called Eisenach in the 18th century. He kept detailed clinical notes on his patients and Duden is particularly interested in his work treating female patients.

Storch’s medical world is that of purges and controlled bleedings and compresses…and yes, leeches.

As Duden states, women’s bodies are conceived in terms of fluxes and flows, a million miles from the biomedical model we have adopted and learnt over the last 150 years or so. In Storch’s world, women go to see the doctor to seek help when they have exhausted their own resources in terms of home-made treatments, advice from friends or just putting up with their state of unwell. I didn’t say “sickness” there because that doesn’t really describe how these women viewed their own bodily dysfunction. Their idea of a state of unwell for themselves was more of a sense of the “flows” being slowed or blocked. Many of this was to do with menstrual flow (as you would imagine).

At no time did any of these women undergo physical examination by the good doctor. Well, not unless they were about to die, actually. Then they might relent and finally give consent to this (in hope of a cure?). In fact, the doctor rarely even touched his patients – societal rules of modesty forbade it.

Many times the doctor never actually saw the patient – again, the status of women in this society (and no doubt low literacy levels) meant that women would often have their husbands or fathers or brothers write to the doctor, explain the symptoms and the doctor would prescribe appropriate treatment or send back compounds for ingestion or application.

As Duden studied the doctor’s writings she struggled to really get in touch with these women through the written word.  Story after story of purgatives and laxatives and compresses and powders and bleeding – so far removed from our modern ideas of bodies and medical diagnosis and treatment. As a woman living in the biomedical model in the early 21st century her view of her own body seemed so distant from theirs…and yet she saw her task as really trying to understand their sense of their own bodies.


To achieve this understanding, Duden gradually realises she has to recognise and then abandon her own embodied sense of self and look at their’s.

When she does this, she frees herself from trying to diagnose them in the biomedical paradigm – and begins to really understand what is going on for them.


She concludes that the nature of the care these women seek is closer to a wholistic one than what we call medical care now.

These women are listened to – really listened to by the physician. Their stories and their interpretations of their illness are  believed absolutely. And of course these stories or retellings of their story form the foundation of his knowledge of their state of being. He literally has little else to go on!

Duden invites us to reflect on our own model of medical care.

The notion of the deus ex machina is Duden’s description of the nature of 18th century doctoring: the deus ex machina is a device that progresses a theatrical performance when things have stagnated a little in the storyline. Something dramatic or magnificent is introduced (think –  a new sports car is purchased by one of the characters on Neighbours) in order to get the show going again.

Where is the physician in this?  In the eighteenth century, the physician is the circuit breaker – visiting him and telling him your story of unwell is a pause in proceedings.

He listens, he prescribes or carries out a procedure – something that you both think might help: a bleed, a powder, a compress to be repeated at home.

There is no promise of cure. Only maybe a hope for improvement – from the doctor and the patient?

And a feeling of having been listened to…of having shared your problems.

Many times, the problem is righted. Sometimes not.  Many times there is no further contact with the good doctor.

Duden gives an example: a 60+ year old woman who has stopped her menses.

He prescribes a compress – she is cured.

There is no rational reason why she should be cured, or even that she needs a “cure” from what we would probably call menopause. The woman defines the problem, the doctor seeks to treat with the knowledge available to him.


 

Is there something present in this style of care that we miss out on today?

I’m not advocating for a return to leeches, but how distant are our bodies from our own selves?

How could we benefit from seeing our bodies as systems of fluxes and flows that need restoring to equilibrium rather than “fixing” by biomedicine?

How do Lactation Consultants support women to breastfeed?

I had the good fortune this week to attend the International Institute for Qualitative Research’s 2015 conference in Melbourne.

I plan to share more about the week’s highlights in the coming days (yes, you are going to be part of my processing the experience…not what you signed up for? Sorry.)

Here’s a copy of the poster I displayed about my beginning PhD research.

Special thanks for Wade Kelly from Charles Sturt University in Wagga Wagga for running a great session last Sunday on “presenting your research”.

I attended. I was inspired by his suggestions. This is what resulted.

Not perfect. But sssssooooo much better than what would have been on the wall without his generous sharing of knowledge. Now to tackle haiku deck.

Hopefully you can read the text by double clicking on the image to enlarge it … this worked on my desktop at least.

Feedback welcome. Also questions.

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Breastfeeding support – what makes it good.

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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 the what 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 breastfeed by their own families!

10 things I want to tell you about midwives.

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.

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About that BMJ Editorial…

Many thanks to anthropologist Aunchalee Palmquist for allowing me to re-blog this response to the BMJ editorial on human milk sharing.

Anthrolactology

A few days ago, the BMJ published an Editorial about the “Risks of the unregulated market in human breast milk.” In a matter of hours, this piece was trending across Facebook and Twitter. Al Jazeera even ran a story featuring this piece. The commodification of human milk is a hot topic, with the Medolac debacle in Detroit, athletes buying breast milk online to enhance their fitness, the New York times coverage of growing profit-driven interests in lactoengineering, and now this.

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