Andrea’s Diary

Lynne Staff and I begin our “Essential Midwifery” tour of the UK today, with an event in London. We have had a lot of fun preparing for this event, which is a variation of the program we presented in many cities in Australia about 18 months ago.

The workshop is designed to follow on from basic programs such as “Active Birth” and to encourage participants to have a closer look at why women (and midwives) are not always having the birth experiences that they want.

The first part of the day looks at the systemic functioning of a maternity unit and what can be done about it. Then we have a closer look at the interactions between midwives and labouring women, using a series of role plays. This is the part that Lynne and I particularly enjoy, both being ham actors from way back!

Lynne tackles the issues of humanising complex births during the afternoon session. She looks at the impact of birth complications on women’s belief systems and encourages the participants, through a series of workshop activities, to explore how they manage difficult birth scenarios in their own units. She has a wonderful series of slides and a video that show women managing difficult births really well in environments of outstanding midwifery support.

The program is designed to encourage reflection, sensitivity and the development of practical strategies that can be adopted by individual midwives as well as by unit managements. It was very well received in Australia and we are looking forward to the reaction from British midwives. I will let you know how we get on…….

The question about the implications of placebos in relation to dealing with labour pain came up again yesterday. I was asked about the use of TENS and also what I thought about using homeopathy for labouring women.

Since there is no scientific evidence that TENS eases labour pain or increases endorphin levels (see the Cochrane Library for the relevant Systematic Review) I have little time for it. It is widely used in Britain and promoted heavily in the pregnancy magazines, chemists shops and even by childbirth organisations. The prevailing view seems to be that it has no side effects and may do some good as a placebo, so why not promote it?

Homeopathy is another can of worms. There is also no scientific evidence that it works, and no-one has yet been able to prove the basis on which it is founded. It again probably works as a placebo, and of course, it is harmless, since the remedies contain nothing but water. I have no objection to people using homeopathy because water is safe to drink, and there is no chance of side effects, overdosing or interactions with other medications.

However, both of these approaches to managing labour rely on women’s fear of pain, bogus claims and the gullibility of women who believe they cannot manage labour and birth without some kind of prop. If the remedy works then they will praise the treatment for its effectiveness. If it doesn’t work, they will just go on to use something else (TENS has never been shown to reduce the rate of epidural use or other drugs, for example).

Why are these crutches being so enthusiastically embraced, and particularly by midwives? What’s wrong with women using these things - does it matter that they are only working as placebos? I believe that it is these kinds of props that feed into the prevailing culture of “learned helplessness” that afflicts many women (and midwives). Instead of recognising women’s inner strengths and capabilities to give birth well, these gadgets reinforce the idea that women can’t manage labour without some external assistance, and as a result, the “victim” mentality, and “poor me” attitudes are reinforced.

I can accept that very, very occasionally, a woman may be so lacking in self belief or appropriate emotional or physical support from others that she needs to rely on these substitutes for care. The popularity of these methods and their growing acceptance and promotion, especially by health professionals suggests to me that women are being cared for by people who either have little faith in birthing women or are lacking in skills to support women during labour using natural means (such as promoting endorphin release).

I think it is time to stop fooling ourselves that women needs these props for labour. Right now, midwifery is undergoing a crisis of confidence and this is rubbing off on women. Let us celebrate our strength and creative capacity rather than selling ourselves short and giving credit to shonky products that offer an illusion of effectiveness. Women need midwives who believe they can give birth using their own resources, and midwives need to see how well women manage labour without external aids. If we are to reclaim birth from the drug companies and the medical men, we need to have a united, confident, visionary belief in the innate safety and power of birth. Without this unshakable faith, we are easy pickings for those who would rather see birth (and women) medicalised and exploited for their money making potential.

The five Israeli midwives in my current workshop group had very interesting stories to tell. They all work together in a big hospital in Tel Aviv where they have about 7,500 babies born each year. It is a public hospital, but all the prenatal care is undertaken by doctors, and the post natal care is carried out by nurses. The midwives are only involved for the births, and they will have had no contact with the women before they meet them in labour.

Some of their practices vary from those we are familiar with, as you would expect. Every hospital, and country, has its own approach to managing birth and it can be a surprise to discover that the procedures that one place identifies as “crucial” are considered unimportant in other institutions.

One such example is cutting the cord - in the hospital in Tel Aviv, the cord is never cut, even if it is very tightly around the baby’s neck. This was not news to the home birth midwives in the group, but was news to regular hospital midwives. The Israeli midwives also showed us a very interesting technique for opening up the sacroiliac joints when more space was needed in the pelvis - the woman lies on her side with her top leg lifted up at an angle, with her knee down and her ankle higher. This causes an internal rotation of the femur and also moves the sacroiliac joint. I am going to investigate this manoeuvre some more as it could be another very useful “trick” for difficult situations.

Although birth is very medicalised in Israel, as you would expect with so many doctors involved, these midwives are gradually making birth more woman friendly. They have introduced baths for easing pain, birth balls and bean bags and are trying to encourage mobility and upright birth positions. They are gradually winning the doctors over, but, as ever, this is a slow process.

Today we will explore a whole range of self-help ideas for labour and I look forward to learning more from these midwives.

I’ve arrived in London - the flight seemed longer this time but it was the usual 22 hours. Have had a quick catch up with Caroline Flint (her practice is thriving ) and a few words with Giles (those of you who were at the Future Birth seminars and heard Caroline talk about Giles will “remember” him, no doubt!).

Lynne Staff arrives tomorrow and we are also meeting up with Tracy Reibel (who was also on the Future Birth tour) in the next few days. Tracy is in the UK as part of her Churchill Fellowship, looking at the way Birth Centres are run in other countries. Sometimes it seems easier to see one’s friends when we are all overseas at the same time…..

The first workshop is tomorrow (Active Birth) and we will have five Israeli midwives in the group. They were unable to come when I was last here in March because the war in Iraq had started and all flights out of Israel were cancelled. I will be interested to hear how midwifery is progressing in Israel, and whether the previous group of midwife teachers who came to a workshop last year have been able to pass on any of the messages from that program.

Learning what happens in other parts of the world is always fascinating. We tend to think that we (Australians, for example) are the only ones where midwives face barriers and difficulties practising, yet everywhere I go I hear the same stories, with variations and regional differences. Later this month I will be in Spain - now that will be interesting!

Last minute tidying up today ahead of my trip to the UK this evening. It will be straight into it when I arrive - I have an Active Birth workshop in London the day after I get there!

The Essential Midwifery tour with Lynne Staff follows for the next week and we will be visiting a number of cities across Britain. This is an ideal workshop to follow on from Active Birth, and I am hoping to catch up with many midwives I have already met through other programs. Lynne’s session on how to keep midwifery principles alive when the going gets touch in labour will enable the group to explore ways of humanising complex births. Given the rising rates of interventions, it seems, sadly, that these will be skills midwives will need to draw on more frequently in the future.

The rising rates for caesareans, in particular, are cause for concern both in the UK and Australia. The feedback from the Essential Midwifery tour will help us shape the programs we have in mind for next year. Planning is already underway for these - the year is slipping away so quickly…..

My next entry will be from the UK. I wonder how things are doing there?

We held a Graduation Ceremony at our office yesterday for Caroline Toolan, one of our students of the Graduate Diploma in Childbirth Education. We don’t normally have the chance to arrange a ceremony because our students learn by distance education and often live far away. The last time I was able to personally hand a Certificate to a graduating student was in Chiang Mai in Thailand when Jiaranai Bhosai completed her Course several years ago.

Caroline has been working her way through this nominal two-year Course for since 1995. Her progress was delayed by a number of factors - a move from Sydney to Perth, extended illness, a move back from Perth to Sydney, several changes of job, marriage and then a home birth 19 months ago. Her story is typical of our students who are usually trying to juggle work, families and study at the same time. Given her perseverance and dedication, we were very happy to grant her request that she receive her Certificate in person. Her husband and son were part of the fun and we had a lovely morning tea and catch up afterwards.

I have now completed the first round of Active Birth workshops for Australia this year and have met all the students in this years Graduate Diploma (this workshop forms part of the Course). They are an exciting group, with varied backgrounds, experience and motivations. The workshop in November will be very full and no doubt, a lot of fun.

I have been reflecting on the Alice Springs workshop I facilitated and in particular the issue of prenatal education for aboriginal women. Planning a suitable program for this group was a task undertaken by one group of participants and it raised some interesting issues.

Birth is seen very much as “women’s business” in Aboriginal society. Much of the education has been traditionally undertaken through observation and involvement in the life of the extended family, with elders imparting specific knowledge as required. Men have not been involved during the pregnancy or at the birth, and appear to play a minor role in baby care and child raising.

Much of this is changing, however, as Aboriginal people move in from the bush to town living, and family support systems shrink. Western ideas are being embraced as young Aboriginal people seek inclusion in the wider Australian way of life. Birth now occurs in hospitals, often far from family and friends. The traditional “women’s business” of childbearing is also breaking down in some places as men accompany their partners during labour and birth in hospitals.

During the workshop, I asked a “naive” question about parenting education for Aboriginal men, either with their women or through separate programs. I may not have put my question clearly, or perhaps it was felt I was being culturally insensitive, as my query was quickly dismissed and it was clear that this was not an issue to be discussed. In these “politically correct” times it is often difficult to raise concerns openly, especially about the Aboriginal community - “white” people may be given the impression that “it is none of their business” even though it may be our money, expertise, personnel and infrastructure that is trying to redress the problems that exist.

When I asked my question, I had in mind the fact that many of the Aboriginal women giving birth in Alice Springs are under age - they are as young as 12 years old. Many are pregnant as the result of rape or have been taken advantage of by men who would be regarded as breaking the western laws of the land . Rape and domestic violence are the unspoken atrocities that occur frequently in Aboriginal communities, and are probably linked to the break down of many of their traditional cultural practices through inappropriate western influences.

If pregnancy and birth remain strictly “women’s business” I wonder if we are inadvertently letting men off the hook and covertly supporting their right to take advantage of women through rape and domestic violence? I know these are hard issues to acknowledge, but why not tackle them openly so some remedies can be sought and the whole community involved? If men were required to take a more active part in the pregnancy, birth and parenting, would this impact on their behaviour by requiring them to shoulder some of the responsibility for their actions?

I am genuinely concerned about the plight of young teenage Aboriginal girls who are being subjected to rape and who have to take risks with their health through pregnancy at an early age. If these cases are hidden as “women’s business” it seems to me that men will never be held accountable for their unacceptable social behaviours and the Aboriginal community will continue to suffer. These things happen in white society as well, but at least white men may end up in court and find themselves jailed for these hostile acts against women. I know that the Aboriginal people have their own laws and ways of dealing with issues that affect their societies, but with the break down of these traditional ways, perhaps perpetrators of domestic violence and rape manage to fall through the cracks and get away with it.

This is a very touchy subject and I may be vilified for raising it, but forcing young teenagers to have babies before they have grown up themselves just doesn’t seem right to me. Involving the men and making them more accountable may be one small part of the solution to this disturbing problem.

This afternoon I will return to Sydney, ahead of an Active Birth workshop in Sydney for the next two days. This has been a very busy round of workshops, and before I leave next Monday for the UK and the hectic schedule planned for that trip, I will be finalising my program for the second half of the year in Australia.

I will be offering more Active Birth workshops in Australia this year than I do usually, because I am concerned that the rapidly rising rates for intervention (our caesarean section rate is hovering around a national figure of 25%) midwifery care is being steadily eroded and our midwives run the risk of losing some of their skills in supporting women without epidurals etc.

When the new models of midwifery care are established (and I remain very optimistic about this prospect) we will need midwives who feel competent to take on autonomous practice as either independent practitioners or as members of small teams. We must find ways to retain the core skills of being “with women” amongst experienced practitioners so that they can mentor and nurture their colleagues in these new ways of working. My workshops are a small step in this process and I will continue to offer them as long as people feel they are performing a useful service (and my stamina holds out!). The year is slipping away so quickly and there is so much to be done…….

One of the most interesting aspects of this trip to Alice Springs for me has been the chance to spend some time with a bunch of really committed and skilled midwives. One thing that has stood out has been the contribution of the “visitors” to their unit - midwives who are working here for a short period while either travelling or taking time out from other work settings.

The chronic shortage of midwives in Australia has meant that midwives can move around with confidence knowing that there will be a job available where they want to stay for a while. For long term staff in a unit, a passing parade of midwives could be seen as unsettling, and a limiting factor in forming close working relationships. However, another more positive way of viewing a high turnover of staff is that each newcomer will bring new ideas and experience. Instead of thinking “oh, no, not another midwife we have to train up to our ways of doing things!”, the attitude can be “you’ll have done things differently - what can you offer us?”.

I have noticed this working very well in the Alice. Around half the staff are long term core midwives and the rest are there on short term contracts (which could be for just a few weeks or up to a few years). Supportive and open-minded leadership has fostered the sharing of ideas and encouraged others to learn from these visiting midwives. As a result, the unit can become more innovative. Midwives who may have only arrived with the intention of a short stay may feel reluctant to leave and either stay on longer or plan return trips. The situation becomes win-win for everyone.

Once again, the key elements in all this are far-sighted managers with clear visions and good people skills. They have these people in Alice Springs. New and exciting plans are being mooted that will enable midwifery to take on new challenges that will benefit the profession and the women of the town. I will be following their progress with great interest.

Yesterday I was shown around the Alice Springs Maternity Unit, which was a delightful experience. The whole hospital has been recently renovated and I was initially taken with their colour scheme - the top floor is done in blue shades (the sky) the second floor in green tones (the plants) and the ground floor in browns and ochres (the earth). There is lots of aboriginal art everywhere too, appropriate for their major client base.

The maternity unit has around 800 births each year. The majority of women giving birth there are now Aboriginal, probably a reflection of the generally falling birth rate amongst Caucasian women in Australia. Many of these Aboriginal women come in from outlying areas, are very young and may have underlying health conditions that can complicate pregnancy and birth.

The birth unit has 16 beds and 4 birth rooms. Each has an en-suite bathroom with either a huge bath or a shower. The rooms have double beds and birth balls and birth stools are in each room. Variable lighting, a variety of furniture and home like decor all add up to very congenial surroundings.

The post natal area has either single rooms or double bedded wards. At first the Aboriginal women didn’t want to be in single bed rooms but the installation of a TV and a phone did the trick! The hospital runs a continuous program of educational videos on breastfeeding, health and parenting videos on the TV as a clever way to reach its captive audience. There are a variety of different “skin groups” amongst the Aboriginal population in the Alice, and it is important to accommodate appropriate women together post-natally, if friction is to be avoided. This sometimes means daily shuffling of beds as women come and go in the unit.

The birth outcomes are outstanding. This is very much a midwifery unit, with a close knit team of midwives who rotate through all areas. Given the nature of this isolated town of 30,000 people, at times they must deal with all kinds of obstetric emergencies as well as regular pregnancy and birth, so these midwives become multi-skilled. Working here is a wonderful way to obtain wide experience in a very friendly and woman centred environment.

Just outside Alice Springs is Pine Gap, a US operated space tracking facility that has brought around 600 American families to the area. I asked how the American women found this midwifery care, which is very different from the medicalised US approach to birth. I was told that they usually come in “demanding their epidural” and discover they can birth well without any drugs, drips or monitors. Most then make a deliberate effort to complete their families in Alice Springs before they return to the US because they love the empowering experience offered in the unit.

I think this says it all about rural birth in Australia - experienced, competent midwives, flexible options for birth, impressive birth outcomes and new mothers empowered through normal births. It is a wonderful model and one we should emulate across the country.