midwifery

Bereavement care. More than just part of the job.

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 …

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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.

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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.

This is definitely a contested space in modern maternity care.

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.

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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.

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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.

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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.

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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.

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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.

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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.

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How do we prepare women to breastfeed?

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.

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Homebirth and other things that matter | Part one

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.

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Once upon a time there was a hospital…

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.

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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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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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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

Maternal and Infant Nutrition and Nurture …oh my!

10 things I learnt and loved about #MAINN2014.

This conference is usually held each year in Grange-over-Sands in the UK, by the University of Central Lancashire. It is a conference dedicated to presenting and discussing research on infant feeding with an emphasis on alternative, contextual approaches to the subject. This year it was held at the University of Western Sydney in Parramatta. These are some of my personal highlights…in no particular order and with ruthless editing to make it digestible to others. Thanks to Virginia Schmied from UWS for making it happen.

1. Exploring the highs and lows of the Baby Friendly Initiative with Fiona Dykes from the UK and Danielle Groleau and Sonia Semenic from Canada. Good to know that there are people interested in the way that health professionals (midwives) live with the 10 steps and the culture of the accreditation.  Fiona spoke about the problems with a “top- down”approach with any behaviour change, but also about the promise of relationships in breastfeeding support.

Sonia spoke about the challenges of introducing the 10 steps into NICU units worldwide: there is a general pre-occupation with infant growth, calories and volume. There are also significant challenges associated with baby illness and feeding. It will be so exciting to see the progress with this work.

Danielle’s work looked at the varied impacts that BFI facilities seemed to have on women’s breastfeeding behaviour in the longer term. She highlighted the  need for more research into the impact of BFI on women from low income groups. She also spoke very clearly about the sociological theory that shines a light on the the problematic issues of breastfeeding cessation amongst women from low income backgrounds and breastfeeding in public. Symbolic capital…mmmm.

2.Renee Flacking reporting on her ethnographic study of four NISC units: 2 in Sweden, 2 in UK. eleven months of fieldwork (phew!).  Her comparison of the different models of care was effective in demonstrating the many benefits of the “womb” model: continuous skin to skin with mother (and/or partner), a separate, private space that allowed families to “focus within”, with the baby as the context.  Interactions between mother and baby “effortless”. Importantly, parents can “be who they are”. Her description of the “standard” nursery care with one uncomfortable chair for mama highlighted the culture in many nurseries of parents being expected to stay an hour or three, but not for longer.

3. Investigations of the impact of peer support for breastfeeding in the UK with Gill Thomson.

Nursing Mothers and the Australian Breastfeeding Association have done this en masse in Australia over the past 50 years. Yup, we reckon it works. Kate Mortensen from ABA is investigating breastfeeding peer support globally and the RUBY study  (Ringing Up about Breastfeeding) will examine the impact of telephone peer support for breastfeeding mums in Melbourne, as presented by Heather Grimes from La Trobe University… it’s already under way.

4. Shanti Raman’s ethnographic study of families in Bangalore,India: “nothing special, everything is normal”. How pregnancy and childbirth is part of the discourse of everyday life in India, and how it is woven into the rich repertoire of celebration and ritual. This resonated with my own experience of providing care for Indian families in Australia… somehow enviable in our culture where pregnancy and childbirth seems so “other”.

5. Gold star to Charlene Thornton for making me like stats!  Her “normal woman” enables effective comparison between care models. Some juicy details: C/S rates, inductions and episiotomy in  private compared to public.

6. Deborah Lupton – renowned health, food and  now digital sociologist.  Enjoyed her quick summary of her own work and directions over the past 20 or so years, with some emphasis on the sociology of risk: “The precious foetus” and more. Mothers place so much pressure on themselves to perform as guardians of their children. Children are both beloved and reviled in our society. Food for thought …

7. Examination of the breast pump discourse: Helene Johns, Kath Ryan and Athena Sheehan. Soft touch indeed. The impact of advertising culture on breastfeeding culture: when breastfeeding comes to equal breastmilk.

8. Talking at meal breaks.  To anyone and everyone – so friendly! What is it about people who do research into breastfeeding and birth? I’d like to think we are uncorrupted by wealth or status!

9. Meeting strangers at dinner. Actually, turned out to be new friends.  This was the kind of conference where, no matter who you spoke to, they were interested and involved in breastfeeding research  and/or clinical practice. Often both. I found out a great deal about what breastfeeding support looks like in Queensland. I also was delighted to share my own plans for research (thanks guys!).

10. Being at UWS in Parramatta. Home of the Whitlam Institute. The campus is an oasis from the traffic and noise of the bustling city.  It’s also a stunning combination of old architecture and new as well as useable and attractive open spaces.  An amazingly culturally diverse community in Parramatta and a calm and beautiful walk each day along the beautiful Parramatta river. Harbour? Who needs a harbour?!

 

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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

Scientific Motherhood

ModernPriscilla1929-03When I was studying midwifery, approximately 100 years ago, I decided to write an essay on parenting advice.

It was probably a pretty crappy piece of work.

The internet was not really something you surfed back then. Research was all about library books on shelves and some midwifery journals (paper ones, in the library).

None of which seemed to have anything to say about this topic.

I can’t remember the major texts I cited back then, but I do remember coming to the conclusion that parents should be encouraged to trust their own instincts with regard to parenting.

Controversial stuff for a student midwife with no experience of parenting at all. Partly, I think I was overwhelmed with the prospect of teaching new parents about something I knew nothing about. Hand it over to them, sister. It made sense.

Turns out maybe I wasn’t so wrong.

The last hundred years or so in the industrialised world has seen a bunch of people termed “parenting experts” telling parents how to raise their children. Given that not so long before that children were usually seen as economic units: mini- adults suited to working in confined areas, like chimneys and sweat shops, I guess it was nice at least that someone took an interest in whether they lived or died.

Mothers were also seen to be solely in charge of child raising (see my post on the Cult of the Mother). Sounds good, but unfortunately they ended up caught in a trap: when concerns arose over infant mortality rates in urban areas in the US, mothers took the lionshare of the blame. Mothers were collectively blamed for poor hygiene, poor diet, not breastfeeding or breastfeeding poorly.

Germ theory made a few things clear, but it took years for the message to get out: babies got ill because of exposure to viruses and bacteria, viruses and bacteria thrived in dirty drinking water, poor people often had to rely on contaminated drinking water…should do something about that dirty drinking water.

The new profession of paediatrics leapt into the task of developing formula for babies whose mothers were unable to breastfeed them.  This was much needed, when so many babies died before their first birthday.  This unfortunately turned into a way to feed babies when women were having problems with breastfeeding, and then, into just a different way to feed your baby. Formula feeding was, initially at least, managed by the medical profession. Paediatricians’ main work was largely in infant feeding plans.

Parenting books started to be written in the 1920’s, but Dr Spock was the breakthrough text in 1946 with his Baby and Child Care. 

The book was predicated on the idea that parents “know more than they think”. There was gentle encouragement for parents to “trust their instincts”. Unfortunately most of the information in the book related to bottle fed baby behaviour. Again parents were gently encouraged to breastfeed, but if it proved difficult, there was always bottle-feeding.

And there were regular reminders to consult with your doctor to check that your instincts were indeed right.

Today there are approximately one gazillion people who write and blog and speak about parenting. Some of these instruct  inflexible and routinised methods to make absolutely sure babies will sleep for long periods.

The good ones let parents know about normal baby and infant behaviour to help them adjust their expectations of what “normal” is (it’s a cycle on the washing machine last time I checked).

Then gentle encouragement to go for that elusive goal: “what works for you”.

A thing I say when talking to parents-to-be in antenatal clinic: “we midwives know a bunch of stuff about lots of babies, but not about your baby …. pretty soon you’ll be the expert there.”

Here are some links to good baby stuff:

http://www.pinkymckay.com

http://raisingchildren.net.au

https://www.breastfeeding.asn.au