Andrea’s Diary

I was reading an interesting article today in the Sydney Morning Herald regarding the way journalists deal with the shocking and stressful events they witness and the high levels of post traumatic stress disorder (PTSD) that are common within the profession.

To quote the author, Geraldine Willessee,  “Many clinicians recognise PTSD as occurring after exposure to life-threatening events. And a large part of the treatment is to talk the events dry of their power”.  When I read these words, I immediately thought of the many women who seem to have an overwhelming need to talk about their horrific birth experiences, especially to those who are pregnant.  We’ve all met these women - sometimes in a prenatal class, where their stories frighten the living dayights out of those in the group expecting their first babies.  Sometimes they offload in post natal groups where the need to find the most gruesome details to recount can become almost a competition.

I have often wondered about some women’s need to go over and over their birth story, re-living the trauma and desperate feelings they experienced as they were giving birth.  I have, of course, read of the possibility of some women suffering form PTSD after especially harrowing or life threatening childbirth experiences, but I wonder if it is not a whole lot more common than we like to think.

There comes a time in many labours (perhaps all of them, to some extent) when a woman feels an overwhelming fear that she cannot go further, that what she is expected to endure is impossible and she will cry out for rescue from the frightening physical and emotional dangers she perceives she is facing. This is normal. It is called the transiiton phase of labour at the end of the first stage and mercifully, it doesn’t last long.  Michel Odent believes that this perception of imminent danger can trigger a sudden rise of oxytocin in response to the surge of adrenalin that is naturally produced when facing a threat and that this spike of oxytocin can lead to the “fetus ejection reflex”, bringing the labour to a speedy end with the rapid and safe birth of the baby. He believes this kind of reaction is designed to shorten labours, which would be of biological benefit both mother and child. He suggests that we should not attempt to “assist” the mother at this time as this may delay the birth and increase the potential for intervention.

The women who talk incessantly about their horrible labours are not, in my experience,  talking about transition, which is often quickly forgotten due to the haze of endorphins that promotes a helpful amnesia around the more arduous work of labour.  Their stories are much more likely to include events that occurred over many hours of labour, often involving various medical interventions that were undertaken either as part of hospital routines or in response to a presumed threat to the baby. Typically, they talk about not being consulted or informed,  a lackof involvement in the decision-making and feelings of helplessness.  Any woman, whose prime goal is to produce a healthy baby, and who is confonted with the news that her baby is in trouble,  may feel she has few options. She may find herself enduring a series of painful or humiliating invasive events, perhaps leading to unimagined personal suffering (physical or emotional)which she is assured, at the time, are necessary for the benefit of her baby

Even though she believes her baby was saved (presuming that it was in trouble), she may have gone through an event she would interpret as deeply traumatic, leaving her to deal with flashbacks, anxiety attacks, depression or other symptions that would fit the definition of PTSD.

De-briefing after birth, with those who were present at the time, is an important first step in acknowledging the feelings that result from all births, but especially those identified by the mother as traumatic. This de-briefing may need to occur on several occasions, perhaps frequently at first but also over a logner period of time. One goal of the process is to help the mother understand what happened and validate its impact. Another is to help her re-frame the experience as part of life, and one from which lessons can be drawn.  Going over and over the story only serves to reinforce the negative aspects and to consolidate the negative memories of the event. A more useful approach would be to find an appropriate counsellor who could assist the woman to identify the positives and draw useful outcomes from the experience, such as her resilience, strength under pressure, protective feelings for her baby, ability to overcome adversity, lessons that have been learned etc.

I believe that PTSD is a very common outcome of childbirth for many women. It is a hidden problem that may lead to an unwillingness to conceive again, rifts in personal relatonships and perhaps even problems with attachment to the baby. Let’s be honest about this issue - it is time to lift the lid on the shameful and needless trauma of PTSD that is often caused by the very system that is supposed to protect mother’s and baby’s health.

Unless this situation is acknowledged and discussed, appropriate care is made available that redues the risk of PTSD, and systems are developed to deal with its aftermath when it does occur, we are going to be hearing a lot more “horror stories” in our classes, our new mother’s groups, post-natal reunions and the community at large. All these stories are fuelling the fear women have of giving birth these days.

Those who promote medical management of birth may think they are saving lives, but at what personal, emotional and psychological cost to their clients?

Many midwives in Australia will remember Sandy Kirkman, one of the most popular speakers we’ve ever hosted on our regular Future Birth seminar tours.

Sandy has had a very distinguished career in midwifery, working in many capacities in England, Scotland and Wales. Her final post, before her retirement last year,  was as Principal Lecturer in the School of Care Sciences in the University of Glamorgan in Cardiff where she completely re-wrote the Doctoral Degree, and  mentored many students.  Sandy also served on the Editorial Board of MIDIRS and The Practising Midwife magazine.   She wrote about many issues dear to her heart and was an outspoken advocate for women and midwives.

One of Sandy’s greatest claims to fame is as a speaker at Conferences and especially in an “after dinner” role. Her anecdotes, stories (often told against herself) and her wry take on the many foibles of human beings have kept hundreds of people entertained, while her witty tales cleverly cloaked important messages about midwifery, childbirth and life in general.  Many have commented that she should have taken up a career as a stand up comic, but if she had, many more would have missed out on her unique approach to midwifery education, which was always one her greatest achievements.

The Welsh Assembly has now recognised Sandy’s contribution by bestowing on her a LIfetime Achievement Award for her services to Midwifery.  This will be presented to her at a special function on December 10, when Polly Ferguson, the Midwifery Advisor to the Welsh Assembly will present the accolade.

I am sure this will be a wodnerful occasion, and one that will provide even more material for Sandy’s accute observations and incisive wit. I am sorry that I will not be there to take part in thefun.

However, there will be an opportunity for Australian midwives to reconnect with Sandy as she is part of the speaking team at the forthcoming Future Birth tour in March 2009.  The full details and registration form for this event is now on our website.

I am looking forward to welcoming Sandy to our shores once again, and to spending some time with her as we laugh our way around the country.

Preparing for Birth: Mothers and Preparing for Birth: Fathers are the best selling books on childbirth in Australia.  Almost 30,000 copies are sold each year, distributed mainly by hosptials as part of their preparation for birth and parenthood programs. They make a stylish and professional addition to the classes and ensure that parents get information they need to make informed decisions about pregnnacy, labour birth and the early paost-natal period.

Last year I was asked by Nanako Ona of the Japanese Birthing Association and the Birth-Sense Institute in Tokyo for permission to have these books translated into Japanese, for sale and distribution through the network of  classes she oversees in Japan.  As I have worked with Nanako before and visited Japan to present workshops for her (with the support of the Australian Embassy in Japan), I was very excited by the proposal. We have worked for a year to get the translation done, through my Japanese translater Yoko Yuille, and the results look terrific (even if I can’t read a word of them!). They’ve used all the original illustrations and we’ve only changed the text where local conditions are different, for example with diets, drug use, labour and birth procedures etc.

Some years ago the Mothers booklet was translated into Thai and it sells there through bookshops, with the proceeds going to the Birth and Breastfeeding Foundation of Thailand.  I am also hoping that the Mothers booklet might be translated into Farsi as well, for use in Iran.

If anyone wants a copy of the Japanese version for use with a specific client in Australia, I have some available.  Send me an email……

As mentioned in  my previous entry, childbirth education in Iran is in its infancy. The first classes only began about 2 years ago, and were modelled on a program an Iranian midwife had used in France. This is fine as far as it goes, but it has huge gaps, especially in the area of labour and birth.

Given that birth in Iran is totally interventionist, it is surprising that the obstetricians have been able to continue on this path without any questioning or opposition, especially from women.  If the whole subject of labour and birth management is omitted from even the few classes that now exist, then this state of affairs will continue.

Women need information about a whole array of topics, from hospital routines, to the drugs, obstetric procedures, complications and caesareans that are so prevalent.  At present, the prenatal program contains a short lecture on the stages of labour, but nothing about how the birth will be managed.

The training program that had been developed to provide educators with the necessary skills to facilitate prenatal programs is also very sketchy.  I have now sent them copies of the training course program and curriculum that we used with our Graduate Diploma in Childbirth Education. There are elements within it that may be useful as a starting point for developing an appropriate course in Iran.  I am hoping that they will set up a distance education package, adminstered centrally, because with such a large country, this would provide the best access for student educators.  It would also help maintain consistency and quality, something that is difficult to manage when the training is decentralised through many universities as now happens.

During the workshop, we again tried out a number of teaching stragtegies and activities that can be used in parent education programs. Although these were enjoyed by the midwives at the workshop, I suspect that they didn’t really “get it” in terms of using these in an actual class with pregnant women - they seemed to focus more on their traditional teaching methods which are all didactic in the style of most university education.  This is another reason why I believe a centrally orgnaised training program will be more effective and innovative - if the key trainers do “get it” (and there are some switched on women in Iran) they will ensure that they train educators to provide classes that are fun and interactive and not a series of lectures or school-like lessons.

“What’s labour like” (above and below) always generates lively discussion.  I was particualrly interested to see how this activity was interpreted as most of the group only have a theoretical knowledge of normal physiological birth.

We also had fun with “graffiti sheets” on changes in pregnancy  (below).

We also had some very interesting disucssion about “the breathing” and the “relaxation”, as they have been using ideas that are rather out of date, and frankly useless in the Iranian context.  As I pointed out, it is waste of time teaching women in how to “breathe” and “relax” in labour when they will be lying on a bed trying to cope with an array of humiliating obstetric procedures.  No amount of training or practise will work in the face of ongoing physical abuse resulting from serial vaginal examinations from a parade of unkown junior doctors and registrars.  To lead women to believe that the training will make the birth less painful is also dishonest.  A solid course in how to say “NO!” might be of better value.

I will be interested to get some feedback from the team in Iran and to hear their thoughts on the training course I am suggesting.  Women in Iran deserve a better deal during pregnancy and labour and I believe that better education will be an important component in bringing about the necessary changes.

I have just returned from another mission to Iran, where I am working on a project to improve the childbirth practices for women and babies for the Ministry of Health and Medical Education. This has been my third trip, funded through the UNFPA, and it is pleasing to see that some improvements are now in place and that efforts are being made to take these further.

The main effort has focused on the establishment of eight centres where normal births can occur. These are located in Tehran (2 centres) and 6 in regional cities around the country, including Mashad, Gorgon and Tabriz. Each has been provided with some basic equipment that would be found in a typical birth centre such as a bath, access to a toilet and shower, floor mats and birth balls, some privacy and more space.

In Iran, obstetricians are totally in charge of childbirth and midwives play a subservient role, acting as obstetric nurses. It was encouraging to have several obstetricians tell me of the great success they are having with physiologic birth in these new centres. It certainly helps that virtually all obstetricians are women in this Muslim country, but also sad that many have chosen caesarean births for themselves, due to the inhuman conditions that prevail in most hospitals.

One of the main goals of this visit was to help set up a program for training childbirth educators in Iran. I feel this aspect of my visit has been less successful than I hoped, for a variety of reasons. It is clear that there is no concept of how a training course should be established and the role of the educator is not clearly defined or even understood. There is a fledgling program in place but this needs to be completely re-vamped so that it reflects adult education principles, incorporates appropriate subject matter and enables educators to develop presentation, communication and counselling skills.

Each of the new centres had set up a program of prenatal education for pregnant women. This is a first - until recently there had been no formal education available for expectant parents. The program that is in place covers the basics of pregnancy and post natal care but is very inadequate when it comes to labour and birth. Women are still not being given any information about the many interventions and medical procedures they will be routinely subjected to in hospital. There are no detailed discussions on shaving, enemas, rupture of membranes, oxytocic drips, forceps, vacuum, episiotomy and caesarean birth. Discussion about the other routines that are carried out, such as no access for a companion, restriction of fluids in labour, hourly vaginal examinations, labouring on the bed, the use of pethidine and nitrous oxide for pain and the routine separation of mother and baby following birth also need to be included.

For many women, giving birth in Iran represents a horrific experience where their human rights are disregarded and they are routinely subjected to humiliating, embarrassing and unnecessary procedure. Many will opt for caesarean birth to avoid these indignities. The Ministry of Health is keen to change this, but it will take a concerted effort on several fronts to improve the birth experiences for women.

I’ve been asked to make a number of recommendations.

First, I have suggested that those hospitals and obstetricians who have embraced normal physiologic birth should be publicised as widely as possible, in recognition of their work and also to alert women that alternatives are now starting to appear.

Secondly, I have recommended that a new course be developed that focuses solely on midwifery. At present the basic nursing course and the subsequent midwifery degrees are too broad, requiring graduates to be competent in areas outside the accepted scope of midwifery such as paediatrics, gynaecology and women’s health. Many of the midwifery courses are taught in part by obstetricians and a standard obstetric text is the basic reference. This is unsatisfactory and has left midwives feeling unable (and unwilling) to take responsibility for the care of women during pregnancy and birth.

The whole area of childbirth education needs a re-think. A clear vision of its purpose, objectives and structure needs to be prepared and a program developed that is separate from mainstream midwifery, preferably administered by a dedicated team of master trainers. I’ll be working with they key personnel within the Ministry of Health on these issues.

Overall, this has been an interesting mission. I was left feeling frustrated by the educator’s workshop I presented, but heartened by my program for the obstetricians. The midwives workshop was mixed - they need a lot of support and encouragement to fully embrace their role as primary health care professionals.

As ever, the Iranians have been generous and gracious hosts. I have been very well cared for (through boundless hospitality) and I feel I have made some very dear friends over the past few years. I hope that I can continue to work with these people as they make further progress in the future.

I have written a number of times about the Doula project run by the Goodwin Centre in Hull. They have recently been awarded for their efforts - this is an outstanding community based program and very worthy of this recognition. Here is an extract from the Press Release I received today:

Date: 8 July 2008

Doulas Delight at Parliamentary Awards

Goodwin Volunteer Doula Project and Hull and East Yorkshire Hospitals NHS Trust and have been honoured with an award at the All-Party Parliamentary Group on Maternity (APPGM) summer reception. The awards acknowledged several maternity units’ inspiring work in improving local maternity services.

Based on four key themes, the Goodwin Volunteer Doula Project and Hull and East Yorkshire Hospitals NHS Trust received their award for developing inclusive services for disadvantaged groups and communities.

‘Heather Barnes, Project Manager for The Goodwin Volunteer Doula Project said “The day was a great celebration for the volunteers and staff who have been involved in the development of this innovative project across Hull. The award recognizes the effort put in by all the volunteer doulas over the past three years, as well as the great team work across the city by all agencies, ensuring isolated pregnant women get the support they need throughout their pregnancy and birth”

Health Minister Ann Keen MP and Emily Thornberry MP, Chair of the All-Party Parliamentary Group on Maternity (APPGM), presented the awards at the Atrium Restaurant, Millbank on Monday.

The APPGM, which is serviced by the NCT charity, highlights maternity issues within Parliament and brings together health professionals and service users with politicians.

The reception was attended by nearly 200 politicians, leading health professionals and user representatives from the maternity services across the UK.

Emily Thornberry MP, Chair of the APPGM, said; “It is a great privilege to present these awards to such deserving and exemplary maternity units. All the entries were very impressive. The winning units are doing innovative work which will act as an inspiration to other Trusts.”

Mary Newburn, Head of Policy Research at the NCT charity said, “We are celebrating the success of these awards as excellent examples of the good work that happens in local Trusts. ”

The Goodwin Volunteer Doula project, developed by Goodwin Development Trust, focuses on listening to the needs of local women from disadvantaged communities to ensure their needs are being met. This pioneering project recruits, trains and matches up volunteer Doulas with pregnant women who need support at what can be a lonely and difficult time. A Doula is a trained and experienced partner who accompanies a woman through pregnancy and childbirth and the first few weeks of family life. The volunteers are trained in child protection, domestic violence awareness, hospital tours, antenatal and postnatal roles, health and safety and breastfeeding.

There were a number of other midwifery projects that also received awards. They are all worthy recipients, and it is wonderful to be able to share these good news stories. I hope you find these inspiring.

Developing inclusive services for disadvantaged groups and communities:

Joint winners

Hull and East Yorkshire Hospitals NHS Trust/Goodwin Volunteer Doula project which focuses on listening to the needs of local women from disadvantaged communities to ensure their needs are being met. The volunteers are trained in child protection, domestic violence awareness, hospital tours, antenatal and postnatal roles, health and safety and breastfeeding.

Ashford and St Peters Hospitals NHS Trust developed maternity services within HM Bronzefield Prison. This includes specialist midwifery care, obstetric ultrasound and high risk obstetric consultant care. Prior to this service, pregnant women within the prison received little or sporadic antenatal care and, in some case, none at all. Since the prison opened in 2004, the Head of Midwifery and the prison directors had regular meetings to discuss the care pathway for pregnant women in prison, and funding was finally obtained in April 2007.

Highly Commended

Pennine Acute Hospitals Trust for employing an ethnic health worker in an area where there is a high percentage of mothers from Pakistani and Bangladeshi communities; she is trained in breastfeeding support, smoking cessation and providing advice on co-sleeping, nutrition and welfare benefits.

Barking, Havering and Redbridge Hospitals NHS Trust where the teenage pregnancy midwifery team has worked closely with young parents and other professionals and community groups to determine what is needed to provide a high standard of holistic care to pregnant teenagers, encompassing continuity of care and support.

The normality of childbirth

Winner

Royal Wolverhampton NHS Trust - in particular New Cross Maternity for the range of measures to introduce and promote a new water birth service, with the aim of increasing normal birth. Over 85% of midwives have been trained and previous waterbirth parents now provide feedback to prospective parents who may want to use the birth pool. They have also provided specific sessions for teenagers and have organised interpreting services for women who wish to attend the preparation classes.

Highly Commended

Shrewsbury and Telford NHS Trust have developed a new midwifery module focussed on promoting and facilitating normal birth. It provides other midwives within the West Midlands the opportunity to address the rising trend in caesarean section rates and raise awareness and understanding on how to promote normal birth within their Trusts.

Responsive, woman-centred, family focussed postnatal care

Winner

Burton Hospitals NHS Trust for the bereavement support service aimed at ensuring those who have lost a baby are treated with sensitivity. An extensive training programme was developed to target all staff who came into contact with bereaved parents and special bereavement care suites have been developed, with ensuites and sleeping facilities for the partner, to ensure parents do not have to receive care in the labour ward.

Highly Commended

Pennine Acute NHS Trust for their production of a light-hearted book which challenges the myths of breastfeeding. ‘Saggy boobs’ aims to raise awareness of the facts about breastfeeding amongst the public and professional bodies.

Involvement of women in providing local maternity services

Winner

Calderdale and Huddersfield Foundation NHS Trust who, despite grassroots opposition to a birth centre, saw the opening of the Huddersfield Birth Centre and Midwifery Led Unit. The key to its success was user involvement and ensuring the Trust listened to what women would value in a local facility through focus groups. A set of evidence based pathways were developed by the consultant midwife to build awareness and confidence in the birth centre concept for the public and local midwives.

Highly Commended

East Sussex Hospitals NHS Trust for its women’s focus group. The group of user volunteers meet monthly to support their local maternity services and work in partnership with the maternity services staff to contribute to the service development within the maternity department.

Portsmouth Hospitals NHS Trust who were nominated for involving women and families in the improvement of maternity services in Petersfield by reopening the Grange Maternity Centre twenty-four hours a day, seven days a week. The Trust was particularly responsive to calls from local families and actively encouraged user involvement in the development of the Centre by asking users to sit on the Maternity Development Group

Mindy Levy is a remarkable midwife in Israel, who has established a birth centre in the north of the country near Nazareth, and who also offers a home birth service. She was one of the driving forces behind both of my visits to Israel. On my last visit, she offered to arrange a workshop for Palestinian midwives, which took place in East Jerusalem in June 2005. This was a wonderful event, if somewhat disjointed due to the langauge difficultlies and the haphazard arrival of midwives due to the onerous checkpoint formalities at the border of the West Bank. The midwives from Gaza had been unable to attend because the border has been closed completely for 4 days by the Israelis.

However, we had an interesting day and Mindy said she would like to follow up wirh another meeting between Israeli and Palestinian midwives. Today I received the following email from her - she has achieved her goals at last.

Dear All,

The last 2 days were big ones- the culmination of months of work and years of planning and dreaming. Sponsored by COHI, nine Israeli midwives and nine Palestinian midwives spent 2 days together at my birth center in Beit Lechem Haglilit talking about women, babies, birth, midwifery and mothering in the Middle East.

It was a party. The atmosphere was festive, loving, hopeful, and professional. We learned much about midwifery on “the other side” and had many opportunitied to explore the differences and similarities, the strengths and weaknesses of each health system.

We understood very quickly that midwives are midwives, regardless of their religion and nationality. Our passion about our profession is universal as are the warmth and love that eminate from our bodies and souls. Midwives are midwives are midwives.

We fell in love with each other instantly. We forgot that there had been a time when we were wary about this first meeting, when we felt fearful of meeting the “enemy” and encountering our own prejudices. There was no fear. There was trust, openness to reveal weaknesses and difficulties, a lot of curiosity, and a great willingness to share and to listen.

We are now planning the continuation of this connection and the sky seems to be the limit. When we parted ways this afternoon, we spoke of when we will meet again, not IF we will meet again.

I feel as if I had given birth- happy, exhausted and overwhelmed. And indeed a birth has occurred- the birth of this incredible project. Now we need to hold it, get to know it, nurture it and some day teach it to walk.

When the birth center emptied I could still feel the energy buzzing in the building- the presence of these midwives was a true blessing for the birth center. I am thankful that I had the honor to host this birth.

In the concluding circle one of the midwives raised the possibility that the end to the violence in our region could be begin by eliminating violence in birth. We all agreed that we really do have the power to change the world, one birth at a time. This might sound a bit much to the non-midwives among you, but this is one of the things that gets us through the pain, blood, sweat and guts of birth, knowing that what we do does makes a difference. Birth is important for both women and babies.

Anyone who feels motivated to support this project financially is encouraged to do so through the COHI website or directly to me.

Mindy

There was small paragraph in the Bangkok Post Newspaper that caught my eye the other day. It was reporting the low rates of breastfeeding in Thailand and the Ministry of Health’s concern that only 5.4% of babies are being exclusively breastfed at 6 months of age.

This low rate probably reflects the growing need for mothers to return to work after the birth of their babies, and perhaps other factors as well, and is probably not very different fro the situation in many other countries.

What attracted my attention was the proposed solution for improving these figures: a publicity campaign to be headed up by a “Miss Breast Milk” (!). My mind immediately wandered to the possible images that might accompany such a campaign…..

Midwifery in Thailand (as opposed to obstetric nursing) has received a boost with the availability of a new course at Burapha University in Chonburi. Until recently, all nursing courses included six months of obstetrics and this has formed the basic qualification of those wanting to specialise in midwifery.

Burapha University has introduced a new post graduate course that will focus solely on midwifery, providing an avenue for those who want to upgrade their basic nursing skills and develop a midwifery philosophy rather than an obstetric orientation in their practise. This is exciting news and will eventually mean more options for birthing women, who will be able to choose midwifery rather than obstetric care for their pregnancy.

Other Universities may follow Burapha’s lead - this course is proving very popular with many applicants for its limited places. Perhaps the next step will be a professional organisation for midwives, that enables them to develop a real identity and voice as health care providers. Knowing about the slow pace of change in Thailand, I won’t hold my breath waiting for that development, but this new course is a very definite step in the right direction.

The birth scene in Thailand is at last changing from one dominated by private obstetrics to one where alternatives, and especially midwifery care, is becoming more available.

I’ve spent the weekend catching up with my friends in Bangkok and learning of the latest developments with the Childbirth and Breastfeeding Foundation of Thailand. This group has been working for some years to promote natural birth and better breastfeeding rates, and although often frustrated by the slow rate of change in this country, they are pleased that their message is being heeded in some hospitals, with outstanding results.

As in most countries, there are two levels of maternity care - the private system and the public health system. In the private sector, the outcome of the birth will depend almost entirely on the practises and attitudes of the chosen obstetrician. With a supportive obstetrician, natural birth is possible, or at least many of the routine obstetric interventions can be avoided. From the information I have gathered this weekend it seems that women wanting to negotiate natural birth options in Bangkok will have the best chance at Rajvithe Hospital in Bangkok (Dr Ekachai), Bangkok Phuket Hospital in Phuket (Dr Suppakit) and at the Samitivej Sukumvit Hospital, also in Bangkok,(Dr Yawaluk, who is a woman doctor).

I have written about the Samitivej Hospital before in My Diary as they have the only Birth Centre in Thailand, but their recent statistics show that support for water birth and physiological management is decreasing, which is both disappointing and alarming. This is probably due to reduced support for normal births from several of their doctors, and it seems that Dr Yawaluk is offering the most flexible approach at present.

In the public sector, there is encouraging news. Smaller community hospitals in rural areas are having great success with upright births (squatting, kneeling etc on floor mats) and mobilisation during first stage. Fathers or other companions are being encouraged to attend and their midwives are very pleased with the good outcomes they are achieving. I have heard great stories about natural births at the Bangnampreo Hospital (in Chachongsao Province, 1 ½ hours east of Bangkok), Somdej-na-Sriracha Hospital (in Sriracha, Cholburi), and Bangtarad Hospital (in Kalasin, in the north east). As often happens, smaller units that are not teaching facilities and where staff have more freedom often produce great results. If a pregnant woman in Bangkok was not able to obtain the care she needed from her private obstetrician, she might want to consider travelling a few hours to get quality midwifery care and the opportunity for a better birth.

The facilities in these small community hospitals may be very basic, with none of the pretty decorations and gleaming technology found in the private city hospitals, but in the final analysis, women in labour are less worried about the decor than the attitude and philosophy of the caregiver who is assisting them. As women discover the benefits of midwifery care over routine obstetrics, and as the successes in these community hospitals become known more widely, it will help drive change elsewhere in Thailand.