Andrea’s Diary

I am working on the report for the Iranian Ministry of Health and Medical Education and the UNPFA following our mission to Iran. We will be making a number of recommendations and suggestions regarding the provision of maternity care that will include: ideas for further training for midwives and obstetricians; the development of new birth centres; the implementation of prenatal education programs; access to research evidence and more appropriate reference books; provision of simple equipment to better enable physiologic births to take place in the current labour wards; and ultimately the reconstruction of maternity hospitals.

This last goal is a long term one, but we have been told that new hospitals are being built now and we have been asked to provide some information on building guidelines and service provision in Australia to help shape thinking in Iran.

The photos below illustrate the urgency of the problem. Until conditions like these are improved, there is very little hope that normal physiological births will occur in current labour wards. The main issue is the complete lack of privacy, which affects both women and midwives alike. Everything being done is on view and while this is a major problem for the labouring woman, the midwives and obstetricians are also vulnerable to being watched over by their peers and supervisors.

The hospital in which these photos were taken is typical of labour wards in public hospitals across Iran.

This is the entrance to the labour ward area.

The nurses station in the centre of the unit. The first stage rooms are on the right and left with the second stage room on the right at the end.

There are five beds in this room. A woman is labouring in the bed on either side of the one shown, behind the curtain. There are two other similar rooms in this unit.

Once on second stage, the mother is moved to this room, where three beds, side by side, are used for managing second stage. In this hospital, which has 1,000 births per month, it is common for two or three women to be giving birth at the same time in this room.

Fathers and relatives wait in this area while the birth is in progress. It was a busy waiting room, opening directly onto the road at the entrance to the hospital. Fathers will see their new baby in the post-natal ward, where women stay for 24 hours (uncomplicated birth) or 36 hours (caesarean birth) before discharge home.

I was pleased with my presentation at the Conference today. I spoke about the “Rich History of Birth Activism in Australia - lessons learned” and offered a snapshot of a few heady years in the late 1970s when Parents Centres Australia set out to expose the awful conditions in which women were forced to give birth in Australia. We learned a lot through our activities and I offered some personal insights into campaigning strategies and tactics.

PCA was a very effective pressure group, initiating the campaigns for breastfeeding support, rooming in, fathers in the labour ward, support for home birth and the establishment of birth centres, amongst other issues. Women in Australia were very ignorant and complacent when it came to having babies - they accepted the indignities and humiliations routinely handed out (soap and water enemas, full pudendal shaving, routine episiotomies, separation from their babies, four hourly feeds etc) as “the way things are done” and stoically put up with it all. PCA, with its outspoken methods, really shook things up. The hospitals were favourite targets and the doctors were regularly lambasted for the pompous, arrogant subjugation of their “patients”. The media were helpful and regularly published quotes and letters and many useful articles were written up supporting the call for change.

Demonstrations were another effective tactic and public displays offered a chance to educate and well as publicise the cause. I was able to obtain a wonderful collection of images of early rallies newspaper cuttings and reports to show this modern day audience how we challenged the system and created an awareness that birth could be better for both mothers and babies. Elaine Normling, an early President of PCA was a fanatical archivist, carefully creating a record of everythign we did. Much of the PCA material is now held in the Jessie Street Library in Sydney (which specialised in women’s issues), but Elaine still holds many of the scrapbooks she collated and generously helped me assemble a collection of images of r this presentation. Here are some that I presented:

One of the first rallies we held was in support of breastfeeding. A number of us set up a display in Australia Square, giving away inflated breast shaped balloons that carried the message “Breasts - not so much the container but what it contents” to a very amused and interested lunch time crowd.
All the media came to film - the balloons with their clever message guaranteed us a place on most TV News programs that night.

The doctors and hospitals information service was another innovation. Using information gathered from the parents who attended our prenatal classes and some surveys we conducted ourselves, we provided useful information to expectant parents about doctors, hospitals and their practises and also revealed hospital policies.

Conferences became regular events. Following the first Conference ever held on breastfeeding in NSW, PCA offered annual events on the themes of birth, breastfeeding and parenting. These enabled us to educate parents and the community while making enough money to support our activities, newsletters, publications etc for the following year.

The full story of PCA, the CEAs and the early history of the Nursing Mothers Association in Australia is well documented in the book “Our Bodies, Our Babies” by Kerreen Reiger. It offers a well crafted account of those turbulent and exciting times that kicked off the birth reform movement in Australia.

The rest of the Conference was a mixed affair. Some of the speakers, especially Justine Caines, offered practical suggestions and exciting possibilities for furthering the cause of birth reform and others were just out to sell a product (the Pink Kit). Needless to say, people were looking for ideas and tips for making a contribution to the promotion of birth and breastfeeding, and became quite hostile to speakers who were into blatant self promotion.

I hope that those who did come to this event will go on to maintain their interest and passion for better births and birth support, for both women and midwives.

This weekend I am at the Australian Birth and Post natal Services Conference being held in Melbourne. This event is the brainchild of Kelly Zantey who has assembled a program of business and birth services speakers that is designed to inspire and uplift, while providing some basic pointers to those who want to become more involved in birth activism.

The audience is a mix of midwives, midwifery managers, childbirth educators and doulas with a few pregnant women as well. It is an ambitious event, and although registration numbers are less than Kelly had hoped, I am sure those who have come will hear some useful information and go away with some new perspectives. Much of the first day has focussed on change and change management, especially in oneself. Being willing to embrace change is a prerequisite to being able to support and influence others to accept and incorporate change into their lives or workplaces. Several speakers offered tips on how to manage stress, develop one’s emotional intelligence, recognise helpful and unhelpful behaviours and understand natural reactions to being verbally attacked.

I was amused how “what goes around, comes around”. At the end of the day we viewed a long film called “The Secret” which was a series of talking heads describing the benefits of what we used to call, in my day (there that’s showing my age!) , “the power of positive thinking”. It was dressed up for the current times in a slick marketing package, and was full of psychobabble, but it basically had a good message - that you are what you think (that’s the “secret”) and if you visualise what you want to achieve, clearly articulating your desires and thinking about the positive things in life, rather than focussing on the negatives (what you wish you didn’t have), then the “universe” will provide the outcomes you desire. It was a message that would resonate with many in a western lifestyle, especially these days with its emphasis on materialism and personal success, but I was disturbed by its egocentricity.

There was no mention of how these insights could be applied to others in the form of service or actions that would benefit the wider world or humanity. The emphasis on getting what you want for yourself is fine, but what about the costs to the community, the environment and the planet that this selfish pursuit of high flying goals (there were lots of expensive gas-guzzling cars shown as commendable “prizes” to be lusted after)? There was no mention of helping the less fortunate, of using one’s influence and skills to obtain better lives for others, or contributing in other selfless ways to the local or broader community.

I would have felt much better about this program if it has included footage of others who had turned their good fortune of being born into western affluence to the betterment of mankind as a whole. Even Bill Gates and Warren Buffet give away a lot of money to worthwhile causes for the benefit of the planet and its people, and while they have almost obscene amounts of money and wouldn’t miss a few billion, it is the principle of sharing what we have with the less fortunate, no matter what our circumstance, that seems to be missing these days.

Kelly Zantey has said that it was this film that inspired her vision of a Conference that would inspire and uplift others to continue to fight for better maternity services. This is a wonderful example of what one person can do in the name of a wider cause. If “The Secret” has enabled her to formulate her plan for this event then it has clearly had the desired effect for her. I just hope that others see the wider application of its message as well.

During the Future Birth tour, the team took time out to visit Selangor Private Hospital in Nambour, about an hour north of Brisbane, Queensland. This unit is unique within the private health care system in Australia and also, I believe, within the health care system as a whole. It works on a collaborative model of care between obstetricians and midwives and has long been th leader in offering VBAC, vaginal breech and twin births and birth in water. For a hospital that has no screening, accepts all-comers and has a higher than average “at risk” clientele (because women will travel from all over to be given the chance of a normal birth) they have excellent outcomes.

A report and photographer from the local newspaper joined us and wrote up this article. We should have checked that the report knew how to spell!

The “Future Birth - exploring new paths to birth” tour has been a huge success. The tour took in six major cities around Australia in eight days - a real travelling circus - and was universally praised on all fronts. The four fabulous speakers provided a wonderful array of ideas, insights and experience that werre appreciated by everyone who attended. Underpinning their presentations was an obvious and deep commitment to women, babies and health and a passion for midwifery that was engaging and inspiring. You can tell that I had a wonderful time, can’t you?

Our tour group: Andrea, Marcos, Polly, Sandy and Sarah

Polly Ferguson opened the day with a clear description of the All Wales Pathway for Normal Birth. This clinical care plan, agreed between all midwives and doctors in Wales, has been responsible for lowering intervention rates, reducing caesarean births and promoting midwifery care through their country. After a long (and exhausting) process of collaboration and discussion, the basic fundamentals of normal birth were agreed and are now applied to all women who want to have a normal birth. In a neat turnaround, midwives assume that a woman who asks to have a normal birth will be offered care described in the pathway, and they will not discuss any alternatives unless there is clearly a medical problem developing in the pregnancy and labour. Recording the woman’s progress is simple - all the midwife needs to do is initial and date each step along the printed Pathway, and make a mark on the partogram during labour - no notes need to be written unless there is a need to explain a deviation. It is a simple strategy that assumes normality from the start, reduces the paperwork during labour and enables the midwife to be much more “with woman”.

Polly will be sending me the evidence underpinning the Pathway that was hammered out during discussion between all stakeholders. Once I receive this, I will upload the Pathway and the evidence onto our website.

In her closing remarks, Polly described how most midwives are “up in the stands” shouting complaints, instructions and sometimes abuse to those playing on the field below. She pointed out that this wasn’t much help and that it was much more fun to be “on the field”, tkaing part in the game. She encouraged everyone to “get their boots on and start playing” - a message that will be taken up by many who will now consider using the Pathway in their own units.

Dr Marcos Dias offered us a rare glimpse into the workings of the maternity health care system in Latin America. He described typical birth outcomes in many of the countries in this region, and what is being done to provide a more humanised experience for women. Marcos is passionate about public health (rare for am obstetrician) and he has committed himself to improving birth outcomes, especially in Brazil. He built the first birth centre in Brazil, in Rio de Janeiro, where midwives are responsible for the care of labouring women. He told us how he had to go to court three times to fight off the doctors (”mothers will die, babies will die”) before it was allowed to open.

Marcos Dias presenting his paper at the Brisbane seminar.

Midwifery as we know it is a very new profession in Brazil, as most women have either obstetric care in the cities, or are assisted by a traditional birth attendant in the poorer rural areas. Marcos is a founding member of REHUNA, the organisation for the humanisation of birth, and was involved in the first two birth conferences on this theme held in Brazil. The first of these was in Fortaleza in 2000 (where I first met him) and then again in 2005 in Rio de Janeiro. There will be a similar event in October 2008, again in Rio, and once more it is expected that around 2,000 people will attend.

Everyone was deeply impressed by this modest man, who is totally committed to women’s health and who is making bold moves to shake up the system through his work as an advisor to the Brazilian Minister of Health. His paper will be on the website very soon.

Dr Sarah Buckley is an Australian GP and mother of four home birthed children who is also a passionate advocate for better birth. Her main concern is the health and well-being of the baby and the emotional, psychological and physical health of the birthing woman. She spends much of her time checking the evidence and scouring the research, assembling an awesome array of scientific data to support her call for undisturbed, ecstatic birth. Her paper was universally acclaimed for its insights and detail, and participants went away with a detailed outline of the impact that birthing practices have on the delicate balance of hormones that are necessary for a successful birth.

Her paper will also be on the website soon, and her book Gentle Birth, Gentle Mothering is a wonderful collection of her writings on this subject, gathered from the many publications to which she contributes regularly.

Sandy Kirkman’s appearance on the program was eagerly anticipated by those who had heard her on the last tour. Sandy is a brilliant speaker, using a hilarious blend of humour and stories to illustrate her message (on this tour) about gender influences on communication. She explained how the different ways that men and women behave and the way they use language can lead to all sorts of misunderstandings, sometimes with unfortunate results.

This can be a particular problem between midwives and obstetricians, who view the world from different gender paradigms. She left us all with some simple instructions that could assist in better collaboration and co-operation, especially in labour ward settings. The first was “never ask an obstetrician for help unless you want him to fix the situation” and “avoid using the word “yes” as a conversation encourager - be direct and simple in your communication with men”. She had some side-splitingly funny stories to illustrate her observations, which left us all uplifted at the end of the day.

Everyone went home laughing, with a broad smile on their face - a rare achievement at a seminar (except ours, of course!).

I am now thinking about the next event, due in two years…..

It is time to get back on the plane for the trip home. This has been a fascinating tour of duty - each of the workshops that I have presented have been completely different: even though the subject was always “active birth”, the composition of each group varied considerably.

The first program in Hull was for the community doula project and the group was mainly made up of volunteer doulas who will be matched up with vulnerable women at risk to support them through their pregnancy, birth and postnatal period. Although some had given birth themselves, they basically had very little knowledge of childbirth, so I had to balance the content to meet their needs as well as the interests of the midwives who were also in the group. Working with non-professionals always presents a different set of challenges and keeps me on my toes!

The next group was in Halifax/Huddersfield, and were midwives from two different hospitals with very different practices. They are in the process of merging campuses, which also involves establishing a new birth centre program. The two groups were a bit suspicious of each other, having heard plenty of “rumours” about each other’s practices. In the end, some new relationships were forged and new understandings emerged - as one said at the end “we all have the same problems, really”. I was very pleased with how this group worked - they went away energised and ready to try new ideas, with a firm commitment to women and their needs above all.

From there I went to Limerick to work with the second year students in the midwifery course. This has become a regular event for me, and it is always stimulating to be around students. Their main gripe was that they were not seeing the kind of care we were exploring in their practical placements - a few had seen birth off the bed, for example, but most were seeing the usual ritualised “active management”style of birth. This was disappointing, as I have done a number of workshops for midwives working in the local hospitals (but not all staff) so I suggested they keep asking the questions that students are entitled to ask - “is this really necessary?”, “is there some evidence you can point me to, to support this practice?” etc. I’ll be back there in 2008 for the next batch of students, so we will see what they have to say about progress.

Next was the Croatian trip, which you can read about above. I am hoping to go back there as well, perhaps to work with the midwives. I would love to be able to give them some more help.

My final workshop was in Wales, on the theme of “The Essential Educator”. The Welsh have really taken to the teaching kits I have developed and have ordered a number of them. This program was for the educators who will be using them, to take them through some of the activities, explain how to make the best use of the materials the kits contains and provide some additional training on group work etc. I’ll be back there later this year as well, as they are buying some more kits and will want further training for their staff.

Wales seems to be the one place in the UK where birth is going ahead in a positive way. Their “Pathway for Normal Birth” record keeping system has been instrumental in reducing midwives’ writing time and freed them up to spend more time “with women”. Their caesarean birth rate is not as high as elsewhere and they have developed some great 1 - 2 -1 midwifery programs in the community and through birth centres. Much of this has been driven by Polly Ferguson, the dynamic and passionate Midwifery Advisor to the Welsh Assembly - you can meet her and get your own copy of the Pathway documents at the Future Birth event in a few weeks. We can learn a lot from the Welsh!

Not a bad series of workshops for a rushed 2 week period! Time for home now, to get ready for the Future Birth tour and make plans for my next foray overseas, which looks like being another trip to Iran, in May.

The year has begun with a rush. After the hard work of putting the 2007 Birth International catalogue together (click here if you would like a copy posted to you), we quickly geared up for the first workshops.

The first program was an Active Birth workshop in Darwin. The “Top End” is a fascinating part of Australia, firmly within the tropics and at this time of the year, a wondrous mix of storms, heavy rain squalls and ever present heat and humidity. The gardens are lush and green, growing rapidly while you watch!

Because of its isolation, the people in Darwin fall into one of two main groups: those who are visiting on extended travels (often work related) and those who have made it their home. The population is young, with lots of children and young families, and the birth rate is quite high by national standards. A number of midwives in the group were in Darwin for a short period, working and chilling out whilst deciding where to move to next.

One thing that is very noticeable in the Northern Territory is that there seems to be plenty of Government money available to support a variety of community groups and programs. There were people from both the YWCA and Anglicare in this group, who are working with the young and pregnant as part of funded initiatives. They were not midwives, but experienced youth workers and they were looking for specific detail to include in their groups for expectant mums.

I also had midwives who worked with the Aboriginal population. Pregnant Aboriginal women are routinely sent in from outlying stations and towns to give birth (a dreadfully disruptive plan, that has major social ramifications for their families) and they congregate in various hostels awaiting the birth of their babies. Many have health problems brought on by inappropriate lifestyles (often the result of intrusion by the white population) and the perinatal mortality and morbidity in this group is disgraceful - real third world standards. Many efforts are being made to address this problem and the training of Aboriginal health works has been a practical solution that is improving results. It is hard to escape the fact that a lack of midwifery care, including birth services, in their own communities must be a major contributing factor.

On my final day in Darwin, the Childbirth Education Association sponsored an opportunity for me to present an Essential Educator showcase for a group of women who are providing prenatal programs in Darwin. CEA Darwin has been very active over many years, and has received finding to set a variety of parent support groups in the city and nearby satellite towns. Their energy and commitment are outstanding!

There was a lot of interest in the extensive contents of this kit, and many agreed that the quality and scope of the activities and resources included would be very useful for their work. Many educators don’t have access to specific CBE training, however using this kit will enable them to offer appropriate and effective group activities that enhance learning for participants.

We had quite a bit of fun trying out some of the activities, especially the Epidural Role Play and the Cascade of Intervention. Everyone felt that these were brilliant for making sure that women were fully informed about these options and these educators could see the potential for using them in their classes.

I left the group to work together on the development of new programs for parents in Darwin, and made my way to the airport to catch a flight to London, via Singapore. After the heat and humidity of the tropics, the cold and wet of a freezing Britain was quite a contrast!

This year has begun with a rush. The usual hard work in putting the Birth International catalogue together (click here if you want a copy posted to you) has been followed with the first “tour of duty” workshops.

My first program of the year was for a group of midwives and eductors in Darwin in the Northern Territory of Australia. It is tropical monsoon season in the north right now, a very spectacular time of massive storms, lots of heavy, sharp rain showers and high humidity. Everything is very green and lush - you can almost see the plants growing as you watch!

The first workshop was on Active Birth. In this part of remote Australia, there is a largely transient population, with many people staying for a period of around 2 years and then moving on. There is a stable group of “old timers” who have made this part of the country their home for many years and one result of the isolation of this region is that there is a tendency for these stalwarts to get stuck in a routine, unless they get regular exposure to developments in other parts of the country. This is true of maternity care to an extent, although as a reaction to the rather medicalised hospital birth system, there is a flourishing home birth population, who have been assisted by a fantastic team of midwives, who have extensive experience of home and water births.

One thing that is always notable about the “Top End” is that there seems to be plenty of Government funding for community based projects. The Territory has a young population, and a high percentage of children and young couples. Community services are available for a whole range of needs and my group had representatives from the YWCA and Anglicare, both of whom are providing programs for the young and pregnant. These women were well trained in group work and group facilitation, and were looking for specific birth information and activities to incorporate into their work.

The Childbirth Education Association in Darwin has been energetically and comprehensively supporting pregnant and post natal women for many years and is well funded by the Government. They have undertaken a number of outreach projects, including establishing new groups in nearby satellite towns, whilst leading the push for better birth services in Darwin itself, offering a range of pregnancy and birth classes and a comprehensive postnatal services.

The new Birth Centre is being constructed at the Darwin Hospital and is due to open in a few months. The policies that will underpin its services are still to be finalised, but it will at last offer a real choice for women who want neither a home birth or a birth in the private or public hospital. I should think it will be especially popular with Aboriginal women who can meet their entry criteria (many have underlying health issues that would exclude them from using the service), as for this group, giving birth near the land rather than on the 6th floor of a tower block is very important. I look forward to checking it out when I next visit.

The final day in Darwin offered me the chance to make a presentation on The Essential Educator kit which many educators have been keen to see. I took them through the extensive components of the pack and there was general agreement that this comprehensive set of teaching materials would be invaluable for many of the programs that are being run in Darwin. Many facilitators don’t have formal training in either childbirth (midwifery) or group facilitation, so a package that enables them to effectively present a variety of teaching activities (with full instructions and scripts) is very attractive and practical.

After a great morning with an enthusiastic bunch of childbirth educators, I headed for the airport and the long trip to the UK.

I had little reaction to my Diary Entry (September 20) about Irish women opting for epidurals. Perhaps people are too annoyed to talk to me, or perhaps they are just muttering between themselves rather than communicating openly. Or else they are not bothered at all…..

However, I did receive this reply and have permission to reprint it here:

Dear Andrea

I recently read the article you posted ‘Irish Women are Wimps’ and was deeply offended by it. I do agree with your views on epidurals and so forth I just take issue with how you present the arguments and with some of your statements. For example I studied Irish womens’ history and therefore am aware of a number of vibrant women’s movements that challenged the patriarchy of the State since the 19th century. Also as far as I am aware despite a vibrant women’s movement in the US, the epidural and caesarean rate is still very high so by this definition are American women wimps as well. I dislike sensationalism and I feel that is what you were trying to do with this statement, it is a very blanket one and I feel it takes from your very valid argument concerning intervention in childbirth. As i said I agree with a lot of what you say, but having first read the headline, I read the article feeling annoyed and angry.

Yours

Mary Tighe (a Irish feminist!)

I responded to Mary as follows:

Dear Mary,

Thanks for the feed back. Yes, I was sensationalist - I wanted to attract attention and get women thinking. I sometimes put a post onto the Irish Midwifery E list, but this is a very “closed” list where midwives and others are afraid to speak out because they fear retribution. Therefore I decided this time to write on my Diary.

There are some wonderful women in the US speaking out, as you say, and I particularly think of Doris Haire, Robbie Davis Floyd and Ina May Gaskin (amongst others). The fact that they have not changed the outcomes in the US is because of the health care system and the vested interests of the doctors and HMOs, but that does not stop them constantly speaking up in the media etc. And yes, I would say that many American women are wimps as well!

In Ireland, I see very little evidence of Irish women speaking out in the mainstream media, for example, about the chronic abuse of women in the maternity care system and the lack of choices for women. There are a few, but they receive little support from their own colleagues, and there is often an orchestrated campaign to undermine what they are saying. Where are the media stories of the shocking abuses that went on in Drogheda? Where is the debate about real choice for women regarding birth place? Where are the voices publicly talking about home births, water births, birth centres and doulas?

What I hear when I visit Ireland (several times each year) are women whispering behind closed doors, afraid to speak out even amongst their colleagues because they fear they will be reprimanded, censured or especially lose their jobs. Until women in Ireland make themselves heard and work collectively and collaboratively to achieve change, then women in the community will not hear of any other ways of managing birth other than the mainstream medical views.

Regards,

Andrea

Does anyone else have any thought to share on this issue?

Tonight I am heading off to Iran, to present a three day workshop for the Ministry of Health. This trip has taken quite a while to organise, involving joining the United National Consultants list, negotiating the program and then obtaining the necessary Visa (which has taken some doing!).

The plan is to provide some in-service training for those making decisions about maternity care in Iran. I have asked for the group to be primarily midwives, as the primary goal is to encourage the development of skills that may assist in lowering the caesarean section rate. Obstetricians are not much help in this regard, as they are usually behind the rising rates of surgical births and are often very reluctant to change. I have requested that the group consist of midwives, policy makers and midwifery educators and it will be interesting to learn who is in the group and how they work in the Iranian maternity services.

I haven’t much idea of what is happening in the Iranian birth scene, but tomorrow I will visit one of the hospitals, so that should be illuminating. I am hoping I can take some pictures, that I can share with my readers when I get home.

My global roaming facility for the internet is not set up for Iran, so there will be no email or Diary entries from me until I get home to Sydney at Easter. By then I hope to have accumulated a number of entries and I will upload them all, along with some pictures, for you to read.

I have been feeling a bit nervous about travelling to Iran, because I know so little about it, but now I am getting quietly excited, and anticipating an extremely interesting week.

The last two days have been spent with a bunch of midwives and educators from all over Cornwall, exploring teaching skills for prenatal programs, and tomorrow I am Iran, exploring birth in a very foreign land. The wonders of modern travel!