Andrea’s Diary

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.

The Birth International Conference in Sydney followed the same basic format as the event in New Zealand, except that to began on Friday afternoon and finished early on the Sunday afternoon. Since most participants were from interstate, this format made travelling easier and also provided for some extra downtime.

The speaking team was much the same as in New Zealand, but there were some variations:

Mary Nolan PhD, Professor of Perinatal Education at Worcester University, UK. Her Plenary presentation was “Childbirth Education - inclusive or exclusive?” and she facilitated workshop sessions on “Putting the WOW! Factor into classes” and “Managing cultural diversity“.

Penny Simkin, Physical Therapist and well-known international author and speaker. Her Plenary addressed the issue of “When sexual abuse survivors give birth” and her workshops were on the themes of “Pain in labour” and “Working with abuse survivors“.

Lorna Davies, Midwifery Educator and author from Christchurch, presented a Plenary on “The art of childbirth education” gave workshop sessions on “Creativity and self expression in prenatal programs“.

Paul Prichard, from Good Beginnings, presented a Plenary session on “Realising the potential of expectant and new fathers” and also facilitated workshops on “Inside the mind of the expectant father”.

Shea Caplice, Midwife and film maker, presented the film “Hannah’s Story” in one of the Plenary sessions.

Judy Cottrell, Midwifery educator from Auckland, presented her workshop on “Action teaching.”

Andrea Robertson, Director of Birth International ran workshops on “Beating educator burnout” and “Teaching birth basics: making birth easier”.

Julie Clarke, independent childbirth educator from Sydney gave workshops on “Getting started as an educator” and “‘I can do this!’ - teaching second stage”.

Allison Hilbig, Women’s health physiotherapist from Melbourne, gave two sessions on “Linking sexuality and birth“.

Lina Clerke, Midwife and childbirth educator, facilitated two workshops on “From fear to excitement about birth - changing mindsets“.

Alesa Koziol, childbirth educator from Melbourne, facilitated the workshops on “Teaching birth basics: drugs and interventions.”

Deb Galloway, Parent Education co-ordinator from John Hunter Hospital, Newcastle, ran the workshops on “Making connections with early parenting”.

Overall impressions of the event:

Once again, this was a very successful event. There were over 100 participants, who offered very positive feedback about the program, speakers and overall organisation.

The venue was praised for its location and setting by the beach, although some would have liked a more central venue so they could go shopping! The cost of t he accommodation was mentioned by some as expensive, but people appreciated the food and general atmosphere.

Some of the general comments included:

“This has really brought me back to the core essence of being woman and birthing with power!!”

“Brought everything into perspective and gave me ideas to work with.”

“Considering the cost, would have preferred to stay a few more hours to get to all the sessions.”

I enjoyed this…”because I learned so much gained new ideas as well as met so many amazing people.”

“The company of so many like-minded midwives - what’s not to enjoy, surrounded by all their enthusiasm. Always glad to hear how other people do things.”

“Catering magnificent”

“Expensive for the value, poor dietary choices.”

“Nice hotel but could have been in a cleaner area of Sydney.”

“Thanks for a wonderful weekend. I feel proud to be a midwife and childbirth educator. And now, even better equipped to care for women.”

“I’m so glad I came along.”

The Plenary sessions

These were enjoyed by everyone - many mentioned the moving film made by Shea Caplice of “Hannah’s Story”. Feedback included:

“Every student midwife and midwife needs to see Hannah Dahlen’s film - I will recommend this at work.”

“Congratulations on Hannah’s Story. Loads of admiration for all concerned.”

The workshops

Every workshop group is different and this can colour both the learning and the overall impression of the program. Many asked for a longer program another time so that all workshops could be attended - people don’t like to feel they have missed out on anything.

The program for Sydney had been devised in two streams, one for “beginners” and the other for more experienced educators. This attempt to tailor the workshop content to the needs of the participants seems to have been largely lost in translation - no-one mentioned that they had taken advantage of this strategy. I had listed learner outcomes for each session as a guide to both presenters and participants - this didn’t appear to work in all cases.

The feedback was very similar to the comments from the New Zealand group. People loved the diversity of programs yet the common themes that were present in the workshop sessions. The opportunity to try various teaching activities was appreciated and there was much praise for the skill, passion and expertise of the presenters.

This was a wonderful weekend for everyone concerned and we felt very pleased to have made such a professional, relevant and enjoyable event possible.

The first Conference that Birth International has presented in New Zealand was held on the weekend of March 8 and 9, 2008. The team of speakers, and their topics were:

Mary Nolan PhD, Professor of Perinatal Education at Worcester University, UK. Her Plenary presentation was “Childbirth Education - inclusive or exclusive?” and she facilitated workshop sessions on “Putting the WOW! factor into classes” and “Managing cultural diversity”.

Penny Simkin, Physical Therapist and well-known international author and speaker. Her Plenary addressed the issue of “When sexual abuse survivors give birth” and her workshops were on the themes of “Pain in labour” and “Working with abuse survivors”.

Andrea Robertson, Director of Birth International, closed with the Plenary session on “New challenges for childbirth educators” and ran workshops on “Beating educator burnout” and “Teaching birth basics: making birth easier”.

Bronny Handfield, independent educator from Melbourne, showed her DVD on “Birth in the Media” that forms part of her PhD thesis, and also facilitated workshop sessions of “Teaching birth basics: drugs and interventions”.

Julie Clarke, independent childbirth educator from Sydney gave workshops on “Parenting 101″ and “‘I can do this!’ - teaching second stage”.

Lorna Davies, Midwifery Educator and author from Christchurch, gave a session on “Creativity and self expression in prenatal programs“.

Deb Pattrick and Tracy Smith, the midwives who form the Core of Life program in Australia, facilitated sessions on “Working with the young and pregnant.”

Allison Hilbig, Women’s health physiotherapist from Melbourne, gave two sessions on “Linking sexuality and birth”.

Judy Cottrell, Midwifery educator from Auckland, presented her workshop on “Action teaching.”

Gerry Smith, midwife and IBCLC from Auckland, offer a program on “Motivating women to breastfeed.”

Overall impressions of the event:

The overwhelming response from participants was that this was an exciting, stimulating event that reignited enthusiasm for childbirth and parenting education and offered many helpful ideas and teaching tips that would be used in future programs.

The Heritage Hotel was a popular choice, and the facilities and food (with the notable exception of the soup on Saturday!) was praised. One person thought the chairs were too uncomfortable and a number of people commented they would have preferred chairs and tables for lunch.

The awful glitch with the A/V equipment on Saturday evening was remarkably well tolerated, no doubt helped by the glass of wine that was available, but this meant the program ran very late, causing problems for some. Saturday was certainly a long day.

The cost was a factor we could do little about - running quality events with overseas speakers is an expensive exercise. Several participants commented that Kiwis don’t mind “roughing it” to get a cheaper event, however I feel that this perpetuates the perception that childbirth educators are “not worth much”, and I prefer to offer as professional event as I can, within reason.

Plenary sessions

These were all praised as being worthwhile. Mary and Penny were applauded for succinct summaries of major issues and opened up conversations that could be continued later in workshops.

“Mary’s talk reduced me to tears in a very heart-warming way. I really appreciated her sharing her family’s story.”

“Interesting. Loved Bronny’s video.”

“Absolutely great closing speech, Andrea. Thank you.”

Workshop sessions

These were very popular and everyone enjoyed the many varied presentations. Speakers were asked to prepare an interactive session that enabled participants to gain skills and try new ideas. Feedback was extensive - here are some examples:

“The talk gave us some great tips on several topics that are often difficult to take - reinforced and revisited learning types - things we knew - but it is always good to be reminded of.”

“Absolutely fantastic looking at diversity and facilitation rather than teaching to or at.”

“Excellent course facilitation of session. Good ideas”

“Great! We are taking her principles straight back to classes! Fab presentation.”

“Very thought provoking. It gave me a new perspective on class participants and ideas.”

“Great. I got to sit in on one of my (s)heros! Great practical information that will really add substance to my classes.

“A very different and interesting session. Stimulating - great ideas. Loved the suggestions for using music, Pictionary etc - thank you. Loved the way you demonstrated your ideas.”

“Great workshop - very concise - they knew their stuff and kept to the point.”

“Wow! Great stuff - very motivating.”

“Good workshop. Definitely will make me tackle this issue more confidently in my classes.”

The event was a huge success, and as we packed up, we were anticipating a similar experience in Sydney, which was scheduled for the following weekend. We were not disappointed…..

The final day of the workshop was a bit crazy. The hunt was on for a woman that we could use to demonstrate a physiological birth and while we waited for someone to appear, we got on with discussing perineums and third stage.

In Iran, women (and obstetricians) believe that an episiotomy is important for preventing later prolapse and also for better sexual functioning after birth. Kirsten did a great job of explaining how cutting the perineum would have no impact on the pelvic floor muscles or the ligaments that support the uterus, as these structures are higher up and not in any way connected to the perineal tissues. She explained that it was the prolonged, over enthusiastic “push, push, push!” style of management that could cause the supporting ligaments to detach from the pelvic bones, leading to the vaginal tissues collapsing into a prolapse. We also talked about the impact of vaginal scarring on later sexual functioning, and the other potential problems associated with routine episiotomy (excessive blood loss, infection, increased pain and discomfort for the woman in the early post natal period etc).

Third stage is routinely actively managed and we spoke at length about how to achieve a physiologic third stage including the first contact between mother and baby.

There was still no sign of an appropriate woman in labour so after a break and another round of tea, we watched the film “Inner Strength”. Some of the scenes in this film were a revelation, causing some giggling, especially the close relationship between the mother and father during labour and the couple that do a lot of kissing and cuddling (a great way to raise oxytocin levels and increase the effectiveness of contractions!). The sounds the women make were also a surprise to many of our audience. As I pointed out at the end, the outcomes we listed for birth on our first day (healthy mother, healthy baby, increased self-esteem in the woman, low morbidity, good memories of birth etc) were clearly demonstrated in this film - this kind of immediate feedback that occurs in a natural birth requires no further exploration - the outcomes are obvious.

Just after morning tea it was discovered that a woman having her second child was in labour following a spontaneous onset. She was about 4 cm dilated with intact membranes. It was decided to offer her the chance to give birth in the new birth centre and she was moved to this area. A relative who works in the hospital was located as a companion (she got bored and didn’t stay in the end). Kirsten went to meet her and with the aid of an obstetrician and a midwife began the process of getting to know her.

The labour was not very well established and of course had slowed due to the transfer to hospital, so the group, who had been watching through a video link in an adjacent room decided to go and look at the area where the prenatal classes take place. Here are some pictures of the class rooms:

The exercise room.

Sign on the door of the video room for watching DVDs etc.

Each session concludes with a relaxation session on this carpeted area.

After lunch, the mother was still just labouring gently. She had been in the pool for a while, which she reported to be very soothing and was walking about. It was decided to carry on with our program, and although some people had left to catch flights back to the provinces, we looked at ways of achieving change in hospital settings and what would need to be done to implement physiological birth in hospitals. I also set out a selection of the wonderful Fotoset images for them to talk through.

Just as we were having our afternoon tea, the word came through the woman was now labouring well and would be getting back in the bath soon. She was 6 cms and powering along. Unfortunately, Kirsten and I had to leave to catch a flight to Isfahan for the weekend, so very reluctantly we left her in the capable hands of a midwife and supportive obstetrician. We will be very keen to hear how she gave birth when we return to the hospital next week for the next workshop.

Meanwhile, we have a couple of days off to explore Isfahan, a jewel in the crown of the Persian Empire and a city considered one of the most beautiful in the Muslim world.

Today was a very productive day at the workshop. We spent a lot of time exploring the practicalities of natural labour versus managed labour, challenging some entrenched practices and applauding some good management strategies.

On the plus side, pregnancy care is comprehensive and up-to-date and epidurals are rarely used in labour for easing pain. The hospital we are in has been designated as Baby Friendly since 1992, which is terrific. On the minus side, the induction and augmentation rate are at almost 100%, as hospitals struggle to manage large numbers of women through overcrowded, shared labour rooms. No privacy, shaving, enemas, restrictions on food and drink in labour, lack of a birth companion, routine episiotomy, lithotomy, and frequent separation of mother and baby at birth are common in all labours.

We spent time trying out comfort positions, using a chair, birth ball, and mat, the only equipment that would fit in the available space in most first stage rooms. Ideas for managing posterior labours were tried out (again not easy due to the coats and hijabs) and we explored how hot water in the form of wet towels could be utilised to ease labour pain. Most hospitals have no baths and showers are in short supply. Hot packs and hot, wet towels are a simple substitute.

The implications of the active management strategy being used here were also examined in detail, first using the “cascade of intervention” activity from the Essential Educator Kit and following up with group discussion around reasons for induction.

Second stage involved talking through normal physiology and demonstrating birth positions.

Here are some photos that Kirsten took yesterday and today:

Front entrance to the hospital with an orange banner announcing the new prenatal classes they have set up for pregnant women.

Workshop participants

Demonstrating how the pelvis works

The new labour and birth room. This room is not quite finished, and is due to open next week. The pool is terrific and there is plenty of space in each of the two birth rooms. An en-suite toilet and shower are also tucked into a corner. The lighting is very bright and will be replaced with dimmable lights (we were assured) and the flimsy plastic curtain separating the two rooms is to be replaced with a door to give better privacy.

The plan is that tomorrow we will try and facilitate a birth in this area as a demonstration to the group. We are hoping that a multip will be available in labour and be willing to give birth in this new area. Kirsten will supervise a couple of the midwives who will assist the woman, while a video camera feed to an adjacent room will make it possible for the large group to see what is happening without disturbing the labouring woman.

We also saw the regular labour rooms today, but were asked not to take photos. It was a dismal, old, cramped area with conditions that would be unimaginable in any hospital in Australia. There were three first stage rooms each with either four or five beds close together, with no curtain to provide even a modicum of privacy. In second stage women are moved to one of two rooms that have three delivery beds side by side in each. This is a Baby Friendly Hospital so at least mothers and babies are not separated at birth and spend either 24 hours together before going home (vaginal birth) or 48 hours in the hospital following a caesarean.

Tomorrow will be most interesting - I wonder if we will be able to show these obstetricians how natural birth can be achieved?

One of the participants in the Essential Educator workshop was Yumi Okoso, better known in Japan by her pen name - Nanako Oba. Yumi is a very well known childbirth educator and birth activist in Japan and quite a TV personality as well. She heads the Birth-Sense Institute, a private consultancy that provides classes and workshops for parents.

In addition, Yumi has set up the Japan Birthing Association, an alliance of midwives, doctors, educators and parents interested in promoting natural childbirth throughout Japan. The Association offers training courses for educators who work with children in schools, offer baby massage courses for new mothers and pre conception programs for couples. They also train educators for pregnancy programs for parents.

As the author of 10 books and the mother of five children (all natural births), Nanako (as she is known to her TV audience) is a frequent commentator in the media, promoting midwifery and natural births.

While she was in Sydney, Yumi and I met with Yoko Yuille who is translating on my books Preparing for Birth: Mothers and Preparing for Birth: Fathers into Japanese. Yoko is a Trainer in NLP, and is herself the author of a book on this subject. The plan is to have my books released in Japan by December, and they will be sold in department stores, classes and through midwives in much the same way as they are sold here. Two of my books The Midwife Companion and Empowering Women are already available in Japanese and are selling well.

We are also looking at ways of translating some of the individual activities in The Essential Educator kits into Japanese. A publishing house in Japan that specialises in medical publications is keen to produce some materials and workshops for those interested in childbirth education and the Kit elements would appear to be ideal. This will be our next project in 2008.

Today I met an Australian midwife who works in the United Arab Emirates, in a small rural centre outside Abu Dhabi. She has been there for five years with her family and has plans to stay for another five to ten years. She loves her work as a midwife, working mainly with prenatal education and postnatal breastfeeding support. Her hospital is the only BFHI accredited hospital in the UAE and she is working towards the reaccreditation by the WHO that is coming up soon

She was looking for suitable DVDs and teaching aids for women with no English and fairly low levels of literacy in their own language. These materials also needed to be culturally acceptable in this Islamic country.

The breastfeeding topic was covered by the “Teaching Breastfeeding” pack which is one of the Essential Educator kit elements. The breast model and DVD that forms part of this pack she felt would fill the bill very well.

Finding a birth DVD was not so easy as most of our range are either water births or show a lot of nudity. In the end she took “What If….” which is short, doesn’t show the perineum during the birth and takes place in a hospital. We added “Hands Off Birth” as this is perfect to show in a country where episiotomy is almost routine and where changing beliefs that the perineum doesn’t stretch during birth can be a tough call. This DVD was made as part of the HOOP trial which proved that keeping one’s hands off the perineum does not mean more tears for women - it’s a very useful film. She also took “Giving Birth, Being Born” as the first half of this film has no spoken words just music to accompany the scenes of women giving birth in a hospital clinic. Again, there are no close up perineal views and the women are all clothed - important for this clientele.

It was fascinating to learn of her work in the UAE and of her happy lifestyle there. I hope she will visit again when she is next back home.

There was an interesting email in my in-box today from a woman who had started to read my article on “Pain in Labour”. This is what she wrote:

“Hi! I just read Robertson’s article on pain in birth. I did not even want to finish it. It is discusting! I wonder if she had any children to suggest that we need pain in labour. Is she from the USA? Another born again Christian? When I had my child I was feeling like I was being cut to pieces for 9 hours! I have not had another child since then! Thank you very much Dr Robertson, you are a neo-nazi!”

Pretty strong words! My guess is that she is still suffering from post traumatic stress disorder and a lot of unresolved grief from the birth of her child. This is what I wrote back to her:

“Thanks for taking the time to give me some feedback on my article about labour pain. I am an Australian childbirth educator (did you check out any other parts of the website?) and have over 30 years of experience of working with women during labur and educating them in prenatal programs. I am certainly not a born again Christian!

I appreciate that you had a terrible time during labour and I know from the research, that many women who suffered terribly either delay future pregnancies for many years or decide never to try again. I also know that many suffer from post traumatic shock disorder, a condition that is rarely acknowledged in relation to birth.

Women are designed to give birth in a way they can manage and handle within themselves. Unfortunately, when the conditions they face are not right, their body naturally takes action to delay or prolong the labour until the conditions improve. This is often seen in the animal kingdom. Sometimes (rarely) there is a physical problem with the baby or the woman that makes labour difficult and a high degree of pain, in the absence of other trigger factors, is a signal that should not be ignored by caregivers. High levels of pain are certainly not normal and need effective remedies.

Perhaps you might consider reading the article again to reach the section where I talk about how birth can be managed to minimise the pain and promote the beneficial hormones that are released during labour.

I am sorry that you have such a difficult time giving birth, and can only hope that you understand that it is highly unlikely to have been a result of your actions, and much more likely to be a fault of the health care system, which failed to give you the nurturing and safety you needed to birth effectively without intervention.”

Labour is such an emotive issue and an event that a woman never forgets. I wish that all women had positive views about labour and that none were left with feelings like this mother’s - what a burden to carry for the rest of your life.

Many of you will have been following the adventures of Jill Moloney, the Australian midwife who works in developing countries where she spreads the word about physiological birth. Recently we sent her some teaching aids for use in the midwifery training in northern Uganda. Jill has sent me some pictures - I am glad the doll is one of our black models! It is going to be loved to pieces!

Here are some extracts from her email, and also her description of the photos:

G’day Andrea and Staff of Birth International,

I just wanted to thank you for the charts you included in the shipment of fetal doll and pelvis sets you sent to us in Uganda in December 2006. We finally received them here in Kalongo (in the North of the country) at the end of last week and they are already a huge hit in our location. I had one brown doll in my bag as I was walking through the town on Friday and took it out when I met a staff member who I thought would be interested in seeing it. She was delighted and couldn’t believe the likeness to a newborn baby. When she finished inspecting it, I turned to go on my way, only to find that there was a huge crowd of people behind me, all eager to inspect the doll for themselves. S/he was passed from elders to grown men and women, teenagers and young children and they all were smiling and wishing for one of their own!!

I have my initial sessions with the staff of the midwifery school and regional hospital on Friday 2nd March and have delivered two doll and pelvis sets and the charts you sent to the midwifery school today. The head teacher and two other tutors were there and they were excited and absolutely thrilled with the quality. They are looking forward to our up-coming sessions about normal physiology of labour and making their services more woman-friendly.

These two men who wanted to see the fetal doll and they played with it for some time. They are sitting in the corner of a restaurant and yelled out to me as I walked past with “Africane” (pronounced Africarn) as the doll has been Christened!

This photo is of Florence, one of our recent recruits in the Public Health Programme. She assists Josephine, our midwife and Traditional Birth Attendant Supervisor, and she is pictured with a TBA who attended a workshop about supporting normal physiology in labour. This part of the workshop was about supporting women in a position of comfort and she demonstrates supporting a squatting position when the mother is pushing, but from a standing start.

Here is Josephine supervising TBAs in the workshop they are “practising” their old skills of supporting women to give birth in a squatting or kneeling position.

Josephine is teaching TBAs about the mobility of the pelvis (lesson taken from your “Empowering Women”book). I am in the photo and have my back to most of the TBAs as I have trousers on and it made it easier for them to see where to place their hands during this exercise.

This photo is taken further into the pelvic mobility part of the workshop where the TBAs are feeling the movement of the ischial tuberosities.