Andrea’s Diary

I received a copy of the Spanish birth Journal “Ob Stare” this week, which has the theme of sexuality and childbirth. Of course, not being able to read Spanish I am at a disadvantage, bur I have two fluent Spanish speakers in my Sydney office and the convenience of having two translators on tap.

This edition of “Ob Stare” includes a translation of my article on presenting sex and sexuality in prenatal programs that appear on our website. This topic came up on the final day of the Effective Pre-natal Education program that we have just concluded, as one of the participant’s presentations was on this topic. It is not always easy to incorporate this thread, especially as it can be sensitive and embarrassing. However, giving birth is the central point around which a woman’s whole sexuality revolves, so to avoid the issue is to deny this aspect of her being.

Ignoring the innate sexuality of pregnancy and birth is, I believe, one of the reasons why so many women find giving birth traumatic. For many women, giving birth is like a rape, with the same kinds of actions and words that would be experienced in a sexual assault. We don’t often talk about this, and I am sure that many women bury the memories as deep as possible, but it is also a potential cause of ongoing post-traumatic stress disorder.

As childbirth educators we can at least acknowledge the close ties between self-esteem, sexuality, pregnancy and birth by finding ways to explain how they are linked, during our pregnancy programs. Women need their strength, innate creativity and sexual power to be acknowledged and celebrated and we can play a part in this during one of the sexiest times of their lives.

The Effective Pre-natal Education workshop is proving most enjoyable. With such a diversity of people in the group, there is lots to discover and share, quite apart from the useful work we are doing on how to organise and present dynamic education programs for expectant parents.

We have two from New Zealand, for example, both midwives. They were surprised to discover that in Australia, women don’t have a known midwife for their pregnancy and birth. Here, women will meet the midwife usually when they arrive at hospital in labour, and they have to take pot luck that this midwife will follow their wishes. In New Zealand, every woman must choose her own caregiver once she is pregnant, and so she has that wonderful continuity that everyone else around the world strives for.

The educator from Finland described how one hospital there (and perhaps more) have fitted each labour room with a bank of monitors that enables the midwife to keep track of the CTG trace coming from all the woman in labour ward at the time. She said that the fathers often watch this bank of monitors: “Look how well the labour is going in Room X. You’re not doing much by comparison”. We were all horrified at this breach of patient confidentiality, apart from the concept of spying on women in this way. I’ve never heard of such a system anywhere else, but perhaps it exists. What away to reduce the intimacy of giving birth to a minimalist set of data! And voyeuristic too - a bit like a camera being set up in the foyer of a brothel so guests could check on progress being made in the various rooms of the establishment…..

The difference between country and city hospitals in Australia has also become apparent from various anecdotes and personal experiences shared by some of the Australian group members. There is no doubt that in country maternity units, largely as a result of the lack of obstetricians or GPs willing to offer maternity care, women have a better chance of receiving midwifery care. Sometimes this can backfire if the midwives are unwilling to try “new” ideas such as waterbirth, or giving birth on a mat on the floor, but generally midwives are flexible and willing to help.

Today we will be tackling program planning and I will be encouraging the group to think outside the traditional models of parent education to explore other program structures that might better meet the needs of parents.

While thinking about Japan, I have also been sorting out my program for next year. It is already starting to fill up, with the Preparing for Birth and Parenthood Conference in Australia (February), the Home birth Conference in Bristol, UK, in March and a training program for the UNFPA in Iran in April. Once again we will be presenting the Preparing for Birth Conference in the UK in July this time. There are also a number of other workshops scattered in and around these events

Meanwhile, I am working on a series of new teaching aids and some fantastic new products we will be launching in early 2006. The next catalogue is taking shape and will be finalised in late December, ready for printing and distribution in January. It is always fun deciding what is out and what is in, especially with so many books, videos, teaching aids and birth equipment on offer.

Next week we being the Effective Prenatal Education program in Sydney. This is a five day intensive workshop that will equip childbirth educators with they skills they need to facilitate parent education programs: working with groups, program planning, managing group dynamics, effective presentations, using teaching aids and a whole lot more.

The people in this group are from all over: New Zealand, Finland (!), Singapore and some from Cairns, Adelaide and Sydney. It will be fascinating to work with these women from such diverse backgrounds and places and I look forward to learning more about what they are doing.

These past few days I have been preparing my presentation for a trip to Japan that will take place in early December. It’s been eight years since I last visited Japan (the time just flies!) and I am looking forward to discovering what had changed in the Japanese birth scene since my last visit.

I remember being impressed last time by the lack of concern about the length of labour, as long as all was well and some progress was being made (partograms were not much in use), and of course, the stoical Japanese attitude to labour pain. Dealing with pain of all sorts, without complaint, has been a hallmark of Japanese culture for centuries, and noisemaking in labour has been frowned upon as an outward show of not being about to cope, and therefore a display of weakness.

I gather, from the information that my hosts have sent me that the epidural is now being promoted for use in labour. I don’t as yet know how widespread it is it, or what local attitudes to it are, but I will be investigating this as soon as I arrive. Japan has always had very low perinatal mortality statistics and low rates for caesarean birth too, and I wonder if these are being influenced by the more aggressive medical approach that I understand is taking hold.

I will be present a one-day training course for educators, another day long workshop for midwives and doctors and then participating in a forum for parents with a group of obstetricians and midwives. Three very different programs that will give me a chance to learn a lot about their country, as I explain what is happening in the west and how we can “keep birth normal”. More later.

Childbirth and midwifery are endlessly fascinating, at least for me. The same biological process, but handled in some many different ways by women and their caregivers that no two births ever end up the same.

I love reading about birth and its management in different cultures and different eras. Three books have come my way recently that I have really enjoyed reading, all offering different perspectives on birth in very different cultures.

“Call the Midwife” is an account of training to be a midwife in the immediate post-war period on the 1950s in the Docklands area of East London. These days, this area is all glass, chrome and high rise office/appartment towers. Back then is was a bombed out area of rubble interspersed with rows of run down, squalid tenements housing thousands of residents and displaced people, all crammed together in appalling conditions. Into this scene pedalled the midwives on their bicycles, tending to the many women who struggled to give birth in less than optimal conditions. Reading this account brought to life the many personalities, the simple dignity of women and the normalcy of birth, which was handled without fuss, in stoical, cheerful fashion. Such a contrast to today! I really enjoyed the many birth stories and the humorous descriptions of the area and its population.

“A Pleasing Birth” takes a good look at how the Dutch have achieved their outstanding results in maternity care. Although more academic in its approach, it is written in a narrative style, engaging the reader in its absorbing message. The political climate in which the Dutch health care system resides is unpacked, and the approach to providing birth services is carefully examined, along with attitudes, training and the practical measures that underpin the provision of midwifery care. Everyone admires the way the Dutch have kept the home birth option alive and strong, and this book explains how this is has been achieved and maintained.

“Midwives’ Tales” is about giving birth in Samoa and is a collection of stories about the changing face of midwifery in this island nation. Many of the traditional ways have been retained but overlaid with modern development in maternity care. The education and training of midwives has changed over the years too, resulting in an interesting mix of new and old. The voices of the Samoan midwives are strong and exciting and it is fascinating to hear how birth unfolds in this corner of the South Pacific.

These three books offer enormous contrast, yet are all about midwifery and childbirth. That such a universal process can have so many variations and be handled in so many diverse ways is what keeps me interested. You would enjoy these insights too!

The ozmidwifery email discussion list always opens up the most interesting issues. One of the strengths of the list is that everyone is welcome - there is no “moderation” of the list (that is, screening of who can join or contribute) and as a result we have a wide assortment of subscribers, from midwives, to educators, doulas and parents, with many from overseas countries as well. Their input offers a wide range of insights that helps broaden our views and enables wider insights.

A recent thread has been the bullying and horizontal violence that goes on between midwives. A comment about hospital based midwives began the discussion and there was lively debate about the different qualities of midwives that work in the hospital setting. Some contributors felt that they were being denigrated for working in a hospital setting, when they were really trying (often against great odds) to provide quality care for women despite high levels of stress resulting from pressures from the system and some colleagues. Others commented that hospitals are staffed by midwives of varying quality, with some who could make everyone’s life miserable (both the labouring women and their workmates).

The discussion widened to include the home birth midwives, several of whom contributed comments about how they were received when they needed to transfer and the difficulties of working in an environment where there was little support from hospital based colleagues.

Some parents reported that they were bullied when they gave birth in hospitals, by some midwives who made critical comments or snide remarks. Women are very emotionally sensitive immediately after giving birth and can be easily upset by even well meant remarks.

As th thread came to a close, it was generally agreed that no-one was “picking on” individual midwives on the list, either those working in hospitals or those working independently. Several contributors who had felt miffed were reassured they were not being singled out (we are a polite lot!) but the issue needs to be raised and canvassed. Sweeping these problems under the carpet will never solve them, and open, productive discussion is necessary if we are to ever stop the bullying that goes on.

I was recently approached by a woman in the UK who is setting up a bullying website, and who was looking to link to our site. I checked it out, but found that so far, her site is mainly concerned with school bullying. I suggested that if she extended her area of interest to include the health professions (very fertile ground!), then I would include a link on our site.

She had found us through the excellent articles by Carolyn Hastie on the subject of bullying amongst midwives and horizontal violence in the workplace. If this is an issue that has bothered you, you might want to check it out. I know that Carolyn welcomes emails too, and her contact details are at the end of the article.

The issue of breech birth has come up again. A midwife colleague was off to counsel a woman who desperately wanted a vaginal breech birth, yet was being pressured by the hospital staff to accept an elective caesarean birth “in the interests of her baby”.

Many woman are falling foul of this current obsession with surgical births for breech babies, despite no hard evidence this will routinely give better outcomes, and their desire to avoid surgery. The famous “Term Breech Trial” by Hannah and others has been widely condemned as deeply flawed, since it only examined births managed by obstetricians and in hospital settings. I won’t go into it here, but for those interested this link offers a good appraisal of this research paper. Overnight, obstetricians started to enforce the surgical option on women with breech babies, changing practices that have since de-skilled both midwifery and obstetric clinicians in managing vaginal breech births.

Women with a breech baby, giving the current climate, are well advised to try and encourage the baby to turn itself into a vertex (head down) position during the last weeks of the pregnancy - then the issue of surgery will evaporate and a normal vaginal birth can be anticipated. External cephalic version is usually offered, but this is an invasive, often uncomfortable procedure, that should be performed (for safety) around 39 weeks of pregnancy. Unfortunately, many women are scheduled for their caesarean section by 38 weeks.

A better alternative is to use burning Moxa sticks to provide a heat treatment that stimulated fetal movements. The baby turns itself - much safer and more comfortable. This technique is “do-it-yourself”, easy and straightforward and has a higher success rate than external cephalic version. For full details, instructions and the research evidence that underpins the technique, this article explains all. If your baby is breech, print the article off, follow the ideas presented and try it out. If you can’t find the Moxa sticks locally, we have them available on mail order and can post them anywhere in the world. Click here for ordering details.

It’s my last day in the UK for this trip. In reflecting on this visit, as I try to do each time, it is interesting to see what the big issues have been and what I have learned from the many midwives I have met and the many hospitals I have visited.

While I have been travelling about, I have been enjoying a book “Watching the English - the hidden rules of English behaviour” by Kate Fox. This is a delightful book, written by a social anthropologist, in which she explains why the English behave as they do.

The core characteristic she describes is “social dis-ease”, the chronic inhibition that underlies all social interaction, leading to “embarrassment, insularity, awkwardness, emotional constipation, fear of intimacy and general inability to engage in a normal and straightforward fashion with other human beings.” This may sound rather harsh, but it in fact leads to a very polite society, an obsession with privacy and a multitude of coping strategies that are familiar, such as “don’t make a fuss”, “mind your own business”, “don’t draw attention to yourself” etc.

Kate Fox also explains many other cultural habits that define Englishness such as their wonderful use of humour, their addiction to moderation, class consciousness, courtesy and sense of fair play. I recommend this book to anyone who ever travels or works in England - it will enable you to understand and appreciate what makes this country so interesting and different.

The book also explained some of my frustration, at times, in working with the midwives here. They know so little about what goes on in other parts of the country, even towns or cities close as a few miles away, and seem reluctant to try new ideas or strategies. I can see now that this is in part the English “drawbridge” strategy of retreating into the familiar home or workplace to avoid social contact and potential embarrassment.

Moaning is a national pastime, and often forms the basis of conversation. It is not acecptable to boast or promote oneself and constant complaining is much referred. It is therapeutic and part of the bonding process and is usually humorous in tone and seen as an enjoyable pastime. The down side is that when people write about a new service, such as a Birth Centre, or a caseloading midwifery practice, other perhaps interpret this as “showing off” or being too earnest about their successes - a definite no-no in this country. Moaning about a lack of services etc is much more acceptable, and absolves the complainer from having to do anything about improving them.

There is also the “keeping up with the Jones” element, a manifestation of the class system that pervades British society. A NHS Trust may not want to know what is happening in the next Trust area in case it shows up some deficiency that would put them in a bad light. It almost as if they say “if we don’t know what others are doing, and everyone keeps to themselves, we won’t be embarrassed by scrutiny of our service provisions”. There is certainly little consistency in either services, standards or quality from one NHS Trust to another, even if they are just a few miles apart. It is called the “postcode lottery” here and affects all areas of health care. It can mean that a woman on one side of the street, in one Trust area, can have a home birth, whereas her neighbour over the road, in another Trust area, has no homebirth service available to her.

The “social dis-ease” that Fox describes is also apparent in my workshops. I regularly broach embarrassing topics (the sexuality of childbirth for example) or ask participants to engage in uncomfortable activities (such as introduction games) to show that these things can be done, usually with humour and fun, and that once we overcome their discomfort, much useful interaction can occur.

I understand where they are coming from, and have many of the same English characteristics myself (being an Australian of English descent). However if we are to move forward and get better maternity services for women, some of these natural inhibitions will need to be challenged. It will mean “making a fuss” and “drawing attention” to new and notable programs, lowering the drawbridge to let in new ideas and seeking valuable conversations and interaction with colleagues in other places.

It’s been an interesting month, and I have learned much, as usual. There are many good things happening here with maternity care, but they need trumpeting, celebrating and publicising, so they can be embraced by others and not ignored or sidelined. Perhaps that is my main role in criss-crossing the UK on seemingly endless train and plane journeys - to be the messenger, mediator and communicator that helps to link these groups and individuals up. My next attempt at this feat will not be until March 2006. Meanwhile, I have a huge workload awaiting me in Sydney, where I will land in 2 days time.