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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More women doing it for longer.

There has been some talk lately about the pressure placed on women to breastfeed their babies.

Ninety-six percent of women in Australian initiate breastfeeding when their baby is born (Australian National Infant Feeding Survey, 2011), which is a cracking good statistic by world standards. It’s definitely up with the leading leaders in Northern Europe.

The well-worn promotional phrase “breast is best” may well be at least partly responsible for this excellent initiation rate, although breastfeeding advocates are well aware of a more pressing problem – that of keeping women breastfeeding.

In the first week after birth, many, many women who had planned to breastfeed either give their babies infant formula or stop breastfeeding completely. This is despite the best efforts to promote the World Health Organisation’s (and Australia’s National Health and Medical Research Council’s) recommendations that advise there are specific health benefits to babies when they receive ONLY breastmilk in the first six months of life.

The latest figures state that 15 percent of Australian babies are receiving only breastmilk just as they turn six months old.

The question of why this is happening is certainly of interest to breastfeeding advocates and researchers. There is every reason to believe that women who start to breastfeed plan to continue doing so, but as for many health behaviours, the reasons why women enact and sustain breastfeeding are extremely complex, and, I would say, intimately related to the context of their lives. This means that messages like “breast is best” have some power in people’s decision-making, but may not sustain their health behaviours over time.

More influential in the medium term for women breastfeeding their babies might be things like how much time off work a woman has after her baby is born, how supportive and knowledgeable about breastfeeding her friends, partner and family are, how much timely support she gets from health professionals if/when she has difficulties, how comfortable she is breastfeeding in public or even in front of other family members in her own home, and how much she actually enjoys the activity of breastfeeding.

Madeleine Morris’ new book, Guilt-free bottle feeding argues that women have too much pressure placed on them to breastfeed. Earlier, I assumed that 96 percent of Australian women were breastfeeding because they wanted to. It is unsurprising then, that when 96 percent of Australian women start off breastfeeding, our health system is somewhat geared towards supporting them to continue. The known health benefits to mother, baby and community of women breastfeeding might also explain the enthusiasm with which that support is offered.

As for individual guilt, it is generally unhelpful to blame those who helped you try to achieve the goals you set for yourself. Better to protest about the values of a society that purports to like the idea of breastfeeding, but doesn’t provide sufficient affordable, skilled support and education to those trying to do it.

Morris argues that there is really very little difference between breastmilk and baby formula, despite regularly stating throughout the book that of course breastmilk is the best and first choice for feeding a baby. Also confusing is her argument that women want to breastfeed because it is an activity that is inextricably linked in our society to the ideal of a good mother. Rather, the evidence we have suggests that women start and continue to breastfeed because of the health benefits it confers to babies.

There are also many women who struggle to breastfeed in public, whether because of overt comments or because they are worried about the possibility of comments being made. This situation is not likely to be reflective of a society head over heels in love with breastfeeding mothers.

The bigger question remains: if most women start off breastfeeding, why do so many start giving formula as well or stop completely?

To be honest, we don’t know enough about how best to support women to breastfeed. The Cochrane Collaboration’s review paper on support for breastfeeding women particularly mentions the lack of research examining women’s satisfaction with breastfeeding support. My doctoral research will ask women about their experience of care with lactation consultants. I will also observe lactation consultants in practice and talk to them about their work. I am excited by this opportunity to learn about women’s experiences of getting help to breastfeed. It will also be great to observe and talk with the health professionals who support women to breastfeed every day.

There is a happy ending to this story: the Cochrane review also notes that any form of breastfeeding support is most effective in populations with high breastfeeding initiation rates.images-6