The issue of skin-to-skin.

photo (3)Atul Gawande  is a general surgeon and researcher from North America. And he writes. And thinks.

I “discovered” him a couple of years ago when I read an article of his in The New Yorker on how medicine takes up new ideas into practice (see links below).

In part of the article he described the efforts of public health workers in India trying to instil the practice of immediate skin-to-skin contact for mothers and babies after birth. The proven power of skin-to-skin contact in reducing infant mortality means it should be a natural activity for birth workers to encourage. And it’s an easy thing to facilitate and encourage in the clinical setting. But still it took time for widespread taking-up of the practice.

Gawande’s conclusion was that people are key in creating change in clinical practice.

Health workers with some clinical skills were employed to visit health care facilities to educate on the importance of the practice and also to make connections with practitioners. Practice is a complicated thing. Clinicians go through many processes in order to change their practice. It is one thing to know what the “evidence” is. It’s another thing to incorporate that into what you do. There may be particular factors which prevent the practice from being carried out, and perhaps most importantly, there may be colleagues who don’t share your priorities.

In the case of skin-to-skin contact, I thought of a few obstructions that might occur in a typical Australian maternity setting:

– the need or expectation that other activities will occur following the birth, such as checking the woman’s perineum, delivering the placenta or checking the baby, which skin-to-skin contact may delay or prevent being carried out.

– the desire of family, friends or health workers to give the mother “a rest” from her baby after what may have been a long and difficult labour.

– the belief that the operating theatre environment is too cold for a newborn baby to be unwrapped.

– the belief that a mother having skin-to-skin contact with her baby on an operating table will interfere with the rest of the caesarean procedure.

– the pressure on labour rooms necessitating the transfer of women who have given birth to postnatal wards as soon as possible.  This might mean that administrative tasks take precedence in the activities following birth.

In fact, many of these obstructions were issues in Indian healthcare facilities too!

Gawande’s conclusion in the Indian situation was that this ongoing person- to- person contact was the most effective means of creating change in practice.  Why?

-It meant that the activity was perceived as a priority (why else have someone dedicated to the task of changing practice?)

-It allowed for the clinician to understand all the reasons for the new activity by discussing it with the health worker.

-It gave local clinicians the opportunity to “own” the activity because they could discuss the particularities of their place of workplace with someone else and adapt their practice in a way that suited their context.

-When the practice was increasingly adopted the results could also be observed by the clinician which then had a positive feedback effect…and so skin-to-skin would become a “standard” feature of post-birth care.

And we haven’t even started to talk about breastfeeding…

 

The New Yorker article: http://www.newyorker.com/magazine/2013/07/29/slow-ideas

Atul Gawande’s website: http://atulgawande.com

Advertisements

speech made on leaving the best job ever…

WitchesIt’s almost a year since I left work to start full-time study as a PhD student. So ended ten years of part-time and casual work as a midwife in a major metropolitan maternity teaching hospital.

I hosted an afternoon tea in the postnatal ward – and I made a little speech, because I grew up in a family where making a speech was a way of marking an occasion… and because it all felt like a big thing to be doing.

This month I have started doing a few shifts back there … just to remind myself of the realities of clinical work and to catch up with friends and colleagues. It feels ok.

Jen’s end of work speech. 2/1/2014  

I have loved working here – although some days are better than others! I have great colleagues who care about the women they provide care for. I have met so many inspiring, interesting women and families and had the privilege of sharing what is a life-changing event with them. They personify what I think this place is all about – the highs and lows of human existence. And they let us experience this with them!
Our work as midwives is so important.

Didn’t catch that? I’ll say it again – our work is so important.
From the booking visit in clinic to the last home visit …. Sure we have expertise: we know plenty of stuff about normal pregnancy and birth. But we’re more than that – we’re another woman, we like having a chat, we care about the whole woman and we meet women where they are.
So then we write the dicky little sentences in the antenatal record about holidays planned, sickness in the family, concerns about another child, how last time’s experience is effecting this pregnancy…
And sometimes we are one of the very few people who have taken the time to listen, to care about what’s happening to this woman in her life. We may well be the only positive educational experience she has had. We can be part of a life-changing time for her – diet, exercise, relationships, doing something amazing for herself and her family by bringing a baby into the world.
So I’m leaving being a midwife because I love being a midwife so much! And people have asked me: “why are you leaving and doing this?”
The project I will do about Lactation Consultants is a means of learning how to do research. The masters sparked it for me – I realised there was so much research out there that can help our clinical practice, answer our questions, help us ask more and help us to live with the doubt.
Anyway, so that’s what I’m going to do. And maybe I’ll come back to help you guys do some research too.
Just one thing to finish with … I don’t think we’re very good at letting each other know how fabulous we are. Do me a favour – tell your colleagues – don’t just thank them for their help, but tell them how you admire their practice, their attitude to women, their commitment to caring, their ability to help a woman birth her baby.

And enjoy your work. Thanks

bash the breastfeeding supporter

Is it me?

Probs it is me.

It’s like when you notice women with prams everywhere when you’re pregnant.

Seems to me there’s a bit of beating up of breastfeeding supporters and advocates going on.

Allegedly they (we) are making women feel guilty about not breastfeeding.

Even when a woman has had a bilateral mastectomy for breast cancer (if you must know) … see Emily Wax http://www.theguardian.com/lifeandstyle/2014/oct/18/breastfeeding-mothers-formula-breast-cancer%5D

A couple of my thoughts on this:

1.96% of women in Australia initiate breastfeeding. In my professional experience, first-time mothers who plan to bottle-feed their babies from the go-get are as rare as inverted nipples*. I’m guess I’m saying this is a very small group of women to be getting an awful lot of words written about them. They in no way should be judged for their decision, but I would hope that their decision is an informed one.

2.Women who are feeding their babies at least some formula are more and more numerous as time goes by…85% of Australian mothers, in fact, just before their babies turn six months old. So formula feeding to some extent in our culture is not a rare occurrence, although as to why this is….it’s complicated. But women who are formula feeding shoudn’t really feel like a marginalised group. By six months they are firmly in the majority.

What happens?

Lactation Consultants and midwives and peer counsellors who provide care for women and their newborn babies really  want to help the 96% of mothers  fulfil their goal of breast-feeding their babies.  Women need some/none/mega amounts of support to do this.

Some breast-feeding supporters are over-enthusiastic in the way they explain breastfeeding, or in the way they explain the benefits of breastfeeding. It’s all a pretty embarrassing scenario really, with breasts and nipples and crying babies and stuff.

And it’s also in the context of recovering from childbirth (with maybe one third of women recovering from major abdominal surgery), no sleep, managing visitors and a lack of privacy in hospital, perhaps a lack of general support from home too…

All in all it’s a very challenging environment to be teaching people about a new life skill. No wonder misundertandings arise.

Breastfeeding supporters know that this postnatal environment is a tough gig. It’s neither “technologic nor dramatic”.

They (we) do it because they feel privileged to be a part of this time with a family and their new baby – and all the promise it holds. Many do it because they themselves had difficulties with their own first or subsequent babies. Some do it because they feel that this time is one of the most important in a new family’s life, even though it’s the cinderella of maternity care (few doctors are interested or present, many midwives are more interested in labour and childbirth, it’s all happening in a pretty tricky environment,as I mentioned earlier, of sleep deprivation, post-operative pain, sore bums, bloody pads and renogotiated family relationships).

I’m saying that we’re not in it for the recognition or the laughs.

But we believe that if women set out to do something like breastfeed their baby, we’ll help them to, even when it gets tough.

Because they, and their babies are worth the effort.mother_BFing

 

*very uncommon indeed.