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.
roar_artwork

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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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?

Breastfeeding support – what makes it good.

mera_breastfeeding


 

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!