Andrea’s Diary

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.

Once again it is election time in Australia. The current Government, in power for 11 years, is fighting for its life, as Australians appear very ready for a change. Although our economy is booming and all the economic indicators are very favourable, the real issues are not maintaining our prosperity by backing the current team, but seeking solutions for our ailing health, education and environment. The Government has trumpeted an $11 billion surplus this year as a measure of its success, but the voters want this spent on better resources for our hospitals, more funding for State run schools, making university education cheaper for students and infrastructure and support for alternative energy projects.

The health care system is being especially targeted for action by both parties. Labour has put midwifery into its policy plans and has signalled that it will include midwifery in the Medicare schedule, making it possible for midwives to be paid for their services through our public health system. This will be a big step towards making independent midwifery a viable option for both midwives and parents, although the issue of insurance is still to be resolved. There is still no insurance company willing to offer professional indemnity insurance for midwives, so the only practical solution would be for the Government to extend their own employees insurance to cover midwives. This would make it possible for independent midwives to get insurance, but it may come with strings attached, putting restrictions on the kind of care that a midwife could offer. All of this is to be revealed once the election is over.

To keep the pressure on politicians of all colours and the raise awareness of these midwifery issues (and others of a similar kind that affect women), Justine Caines has launched a political party called “What Women Want”. Justine has been a consumer activist around birth issues for a number of years, chairing the Maternity Coalition and lobbying hard to achieve many of the reforms that have occurred hard in recent years. She has had 5 home births (producing 6 children) and is an articulate and intelligent protagonist for better services for women across a range of issues. She herself is standing for a Senate seat in NSW, and her party has nominated candidates for a number of lower house seats, especially in Queensland, South Australia and NSW, all in areas where the Government hold a tenuous lead.

The campaigning has gone on all year, and although an actual date has not been announced, the election must be held before Christmas.

For those of you who were regular readers of My Diary, you will be aware that it has been some months since I regularly contributed my thoughts through these pages. There have been a number of reasons for this absence.

The old story of “what goes around comes around” meant that I was finding the same issues were arising again and again, and that it was hard to keep addressing the same themes when I had hoped that these topics would be issues no longer. In fact, it might be fun and even useful to look at some of the things I wrote years ago (I started this column in August 2002) and do some updates.

This year has also been rather different for me in other ways, which has affected my writing. I have been travelling less, due to the need to by in Sydney for family and other reasons and therefore there have been fewer adventures to report on. I am also involved in other community activities which has taken much time and energy.

And then one gets out of the habit of writing! Most of my musings are written at the late afternoon as I reflect on the events of the day. Once one breaks this habit for a few days, it can be hard to re-establish the pattern.

On a positive note, I now use Skype to chat to people via the internet. This is ridiculously cheap and very convenient, and it has made keeping communications going with our UK customers much easier. This has been important because we closed our physical office in the UK in December last year and centred all our business in Sydney. I still have a part-time person in the UK who maintains the basics for us, but everything is shipped from Sydney where it is much easier to maintain the inventory etc. For our UK customers, nothing much has changed, and we have a local phone number in London (another Skype service) that means people can leave messages or even call if the time difference is practicable. This number is 0208 123 6659 if you want to speak to me.

coming months are going to be busy. I have a trip to Cairns in a couple of weeks, and at the end of October I am going back to Iran for another tour of duty. More about this exciting trip later. The plans for our two Conferences (Sydney and Auckland) are complete and the programs are on the website. These will be special events, of interest to childbirth and parenting educators, whether they are starting out or have years of experience in this field.

For those of you who were regular readers of My Diary, you will be aware that it has been some months since I regularly contributed my thoughts through these pages. There have been a number of reasons for this absence.

The old story of “what goes around comes around” meant that I was finding the same issues were arising again and again, and that it was hard to keep addressing the same themes when I had hoped that these topics would be issues no longer. In fact, it might be fun and even useful to look at some of the things I wrote years ago (I started this column in August 2002) and do some updates.

This year has also been rather different for me in other ways, which has affected my writing. I have been travelling less, due to the need to by in Sydney for family and other reasons and therefore there have been fewer adventures to report on. I am also involved in other community activities which has taken much time and energy.

And then one gets out of the habit of writing! Most of my musings are written at the late afternoon as I reflect on the events of the day. Once one breaks this habit for a few days, it can be hard to re-establish the pattern.

On a positive note, I now use Skype to chat to people via the internet. This is ridiculously cheap and very convenient, and it has made keeping communications going with our UK customers much easier. This has been important because we closed our physical office in the UK in December last year and centred all our business in Sydney. I still have a part-time person in the UK who maintains the basics for us, but everything is shipped from Sydney where it is much easier to maintain the inventory etc. For our UK customers, nothing much has changed, and we have a local phone number in London (another Skype service) that means people can leave messages or even call if the time difference is practicable. This number is 0208 123 6659 if you want to speak to me.

coming months are going to be busy. I have a trip to Cairns in a couple of weeks, and at the end of October I am going back to Iran for another tour of duty. More about this exciting trip later. The plans for our two Conferences (Sydney and Auckland) are complete and the programs are on the website. These will be special events, of interest to childbirth and parenting educators, whether they are starting out or have years of experience in this field.

Despite my misgivings about midwifery in Thailand, there is one place where you can have a natural birth within a midwifery model of care.

The Samitivej Hospital is a large private hospital in Bangkok, and it contains the only Birth centre in Thailand. Over 20 years ago, Melanie and Dr Tanit Habanananda set about creating a special birth place that would be open to all the active birth concepts they believed were best for women and babies. With the support of the Hospital, they redecorated and refurbished some birth rooms, installing baths, low beds, soft lighting and a collection of simple birth aids (stools, mats, hot packs, bean bags, birth balls etc). Dr Tanit led the way, offering water births and births off the bed, often in squatting or kneeling positions. His success (his personal caesarean rate has been around 3%) encouraged others and several colleagues began offering similar care.

About 3 years ago the Birth Centre was relocated, providing an opportunity for expanded space and new decoration. There are four birth rooms - two with fully adjustable beds and access to more traditional equipment in case of obstetric need and two delightful natural birth rooms, complete with large tubs, regular beds, wooden support frames and discreet lighting. The walls are covered with a collection of lotus flower prints, reminding women of their sacred flower as they labour and give birth.

Even though this may be the most beautiful birth centre in the region, it is the quality of the care that is important. The midwives who work here are a dedicated group, skilfully supporting women through the labour without the use of drugs. The obstetricians who use the centre are open to water births and “alternative approaches”. Their results are excellent and the unit is very popular with the expat women in Bangkok, who are used to midwifery care in their own home countries and appreciate the rare chance to have a similar experience in Thailand.

The Hospital tends to be more modest about its achievements with the Birth Centre than it need be. A facility like this should be trumpeted as world class and promoted as the only place where the routines of shave, enema, lithotomy and episiotomy ( the standard fare in other hospitals) will not even be suggested. Thai women need to learn of the availability of this service - foreigners usually manage to find out about it through their support networks.

Doctors, especially those who are keen to develop a thriving practice, could see the advantages of such a set up. In this unit, women will be able to labour with much less involvement of the doctor, who needs only stay in the background to improve his statistics (reduced caesareans, forceps, vacuum etc) while producing satisfied clients (and collecting his fee!).

Women need more choice when it comes to giving birth in Thailand. This unit is a shining example of how it can be done, with little cost, better outcomes for mothers and babies and increased job satisfaction for staff. The Samitivej is to be congratulated on its forward thinking approach to providing such options.

Following a terrific few days in Japan, I have headed to Bangkok, to do some work for the Childbirth and Breastfeeding Foundation of Thailand. A one-day workshop had been planned as an update on the Active Birth theme and a group of midwives from a number of hospitals and universities came to share their ideas.

There was also a group of midwives frm Vietnam - they were undertaking studies at the College of Nursing and attended with their Tutor. I was pleased I could present the program in English as having to translate into both Thai and Vietnamese would have slowed us down considerably.

It seems that active birth concepts are still slow to be adopted in Thailand. The maternity care system here is dominated by the obstetricians and the midwives (nurses) work completely under their control. There is no real understanding of midwifery as a separate profession as all nurses have six months of obstetric care as part of their basic training. Some do go on to specialise in birth, and would be regarded as midwives anywhere else, although they too have to stand aside for the doctor to manage the birth itself.

There is also no separate organisation for midwives, and it is impossible for “foreign” midwives to work in Thailand. This is such a shame, as Bangkok has a large expat community, including a number of midwives, who could readily provide some on-the-job training and guidance for local staff. I met a midwife from Norway, with many years of experience facilitating home births in her country, who has been totally frustrated in her efforts to use her skills in Bangkok. She mainly works offering support to women pre and postnatally with occasional opportunities to support women in labour. She told me that she has recently had a breakthrough when supporting one woman in a hospital. The obstetrician ws prepared to stand and watch her manage the labour. He was astonished at the ease of the birth and the calm way that the midwife carried out her care. He was very impressed and although there are legal difficulties for her to continue working in this way, she is hoping that some kind of informal “arrangement” can be made with this open-minded man. At least he has seen how birth can happen safely and simply in a midwifery environment. Perhaps he will become a rare convert to the idea that with birth, “less is more”.

As with other medicalised countries, the main stumbling blocks to achieving change are habit (old habits die hard), money (doctors are paid for what they do), territory (they are not willing to have anyone invade their patch) and lack of experience. This last issue is a major problem because unless a doctor has actually witnessed alternative ways of managing labour, it is almost impossible for them to imagine how it can be done, especially their own role. Seeing really is believing when it comes to implementing new ideas.

Without skilled midwives to demonstrate alternative approaches, it makes stimulating change very difficult. The Foundation is planning another round of workshops facilitated by Dr Tanit and Melanie Habanananda (the leaders in natural childbirth in Thailand) and they hope to recruit some others to join their training team. A lot of work is needed to reduce the caesarean birth rate which is now hovering around 70% in the private hospitals.

The workshop was fun and productive. We covered the usual material and discussed local issues. This workshop may become a regular feature on the Foundation’s calendar, to underscore the work they are doing themselves. Many of you will recognise these activities, illustrated below:

Nanako Oba is well known in Japan. She is a childbirth educator with a high media profile due to her enthusiastic support for natural birth and also her five children (considered an excellent role model for others in low-birth rate Japan).

I first met Nanako (also known as Yumi to her friends) at the fantastic “Birth Without Borders” Conference, presented by the Childbirth and Breastfeeding Foundation of Thailand in Chiang Mai (1997). We made an instant connection and have maintained a close contact since, working on ideas of mutual interest. The Birth-Sense Institute is Nanako’s sixth baby - a thriving business that offers a range of courses, training and products.

One of the most popular services revolves around the team of educators that go into schools to talk to primary school children about “where babies come from”. Sex education is very limited in Japan and this initiative aims to answer question while promoting natural birth and breastfeeding at a time when children are still young and forming their ideas.

Baby massage classes are also available and are enthusiastically supported by new mothers.

Preconception classes have also been developed, and Nanako hosts weekend programs in luxury resorts for those planning to start a pregnancy. People come from all over the country to experience some pampering while learning more about preparing for a healthy pregnancy and birth.

Regular prenatal classes are also part of the Birth-Sense program. Recently the Tokyo City Council began paying Birth-Sense to provide free programs for parents living within their area. A team of educators now facilitates these classes, with over 100 couples each month taking advantages of this service.

Nanako has set up a series of training courses to equip educators with the necessary skills for these programs. Developed as a series of four separate courses, each builds on the previous program to enable skills to be gained in an orderly fashion. Potential educators are interviewed and selected based on their background and interest level in the subject matter. Nanako and I are planning to add a fifth step - the new Certificate IV Course for Childbirth Education that we will be launching in a few months. By adding this higher level at the end, Japanese educators will gain a qualification that has some international recognition and standing.

The Birth-Sense Institute also sells a a range of products of interest to parents and educators. You can ind out more from their website or by contacting them directly:

Birth Sense Institute Co. Ltd. 504# 1-9-16 Tomigaya Shibuya-ku. Tokyo. Japan 151-0063. TEL 813-5454-8232. FAX 813-5454-8212

Nanako and I spent many happy hours together during this visit. She very kindly escorted my on a tour of Kyoto, which is resplendent with over 1000 temples and shrines, set in forests on steep hills - a fascinating area. Here we are together outside the famous Golden Temple, where the sun was conveniently setting, illuminating the Temple in the most dazzling display. What a treat!

One of the most interesting things that was discussed in the workshops was the temperature of pregnant women in Japan. Apparently, many pregnant Japanese have low body temperatures and this is thought to cause problems with the labour and birth. When I was asked my opinion about this, I was stumped - in Australia we pay little attention to a woman’s temperature in pregnancy, unless she says she is feeling sick and we want to check for signs of fever.

For Australians, normal body temperature is 37.2 degrees. This would be regarded by many Japanese as being at fever level, especially when pregnant. I was told that Japanese women have a body temperature about a degree lower and many hover around 35 degrees.

This phenomenon is thought to be the result of eating the wrong foods. Traditionally, the Japanese diet consists of vegetables, rice, fish or a little meat - whatever is in season at the time. With the arrival of refrigeration, transport systems, and international trade, many foods are available year round, especially vegetables which can be imported from other countries. This means that pregnant women may not be eating foods in season, perhaps resulting in an imbalance and perhaps a lowered body temperature.

I formed the impression that during pregnancy, a woman’s temperature is measured frequently and much advice is offered about the importance of a good diet. No arguments there! However, I was also told that women are often required to observe a strict weight gain of no more than 8 - 10 Kgs for the whole pregnancy. This may not be difficult for Japanese women to achieve given that they are often of small stature and slightly built. However, I wonder if the regular bouts of starvation sometimes used to attain the desired weight each month of pregnancy results in women’s metabolism being impaired and their body temperature to fall. Could they be underfed and therefore cold?

When I was asked what should be done about this problem of women being cold and therefore not labouring well, all I could think was to get them warm - pop them into a hot water bath or wrap them up in a blanket. Perhaps some nourishing food at the start of labour might help too.

Aren’t the birth customs and culture in different parts of the world interesting?

This program was facilitated by the Japanese Birthing Association with the help of Austrade (the Australian Government’s overseas business assistance agency). Nanako Oba, the driving force behind both the Birth Sense Institute and the Association, had been working with the Australian Embassy in Tokyo on another project (importing Australian made organic cotton sanitary pads) when she approached them for help with the workshop. A venue was needed and help with translation.

The head of Austrade in Tokyo, Catherine Taylor, was enthusiastic and readily offered help. She has two small children herself, and had had good birth experiences in Tokyo. She knew of me already, as her sister had sent her a copy of Preparing for Birth: Mothers when she was pregnant and so she was pleased to have the chance to support my work in Japan. The Embassy staff were very welcoming and the facilities were excellent. My two translators, Mai and Airi were fantastic, and got right into the subject matter, being young and single themselves.

The group was made up of midwives from many hospitals, and some had travelled from the furtherest reaches of the country to attend. Several were involved with midwifery education and a number of independent midwives also came. It was a diverse group and we had a lot of fun working together during the two days.

The Japanese translation of my book, The Midwife Companion, will be published in March 2007. I have been working with Yoko Yuille (who translated for me at the workshop in Tokyo last year) as she now lives very conveniently in Sydney. The publisher is very excited about this book and there are already many pre-publication orders. I hope it enables more midwives to develop their skills around being “with women” and encourages midwives to stay working in this field.

There are other joint projects between the Japanese, the Australian Embassy in Tokyo and myself in the pipeline. I have really enjoyed working with these wonderful people and believe that we can make a difference for women giving birth in this amazing country.

During the past few days I have been in Japan as the guest of the Japan Birthing Association and the Birth Sense Institute. It has been another fascinating trip, and one in which I have learned a lot more about birth in Japan.

There is a strong sense of midwifery in Japan, although this is under threat (just like the rest of the world!) mainly because of the diminishing number of midwives due to retirements and a shortage of obstetricians many of whom are also reaching retirement age. The response of the Government has been to attempt to concentrate birth into large hospital facilities where the presence of a doctor can be guaranteed in a time of need.

This has meant that many of the wonderful “midwife houses” that dot Japan are closing. These mini birth centres offer a real “home from home”. Instead of labouring in one’s own home, which in Japan may not be entirely suitable for a home birth, the woman goes to the midwife’s house, where they give birth on a tatami mat, and stay cocooned in a quiet, cosy room for the next five days. All meals are provided and there is a constant presence of a midwife who helps with breastfeeding and any problems.

During this trip I visited another Midwife House in Tokyo ( I have visited others on a previous trip) and it was lovely to meet Shoko So, the midwife, and her sister Akiko Miyakawa, who offers a variety of complementary therapies including massage, acupuncture and aromatherapy through an adjoining clinic. There were two women in residence, both of whom had given birth in the preceding days. One had her other child with her and the whole family could stay with her overnight until she was ready to go home.

Here are some views of Shoko’s Midwife House

The birth room

Clinic room - note the footprints around the wall!

Birth announcements

Preparing dinner for us in the kitchen

L to R: Akiko, Shoko, myself and Nanako Oba from the Birth sense Institute

One of the new mothers

Newborn in his traditional kimono (kimonos are worn for the first 3 months)

The entire setup is delightful. The house is just another in a quiet residential street and birth is clearly part of the local community. The births are rarely complicated and many women give birth in the pool or tub. Transport can be arranged to a nearby hospital if needed.

At the present time, Japan has a very low birth rate, and the Government is trying to encourage women to have more babies. If all women could have access to a midwife house like this one, then surely women would find birth such an enjoyable experience they would want to have another baby, just for the pampering alone!