Andrea’s Diary

For the next two weeks I will be in Iran, once again facilitating workshops for the Ministry of Health. There will be three workshops, two three-day events for obstetricians and a one-day follow on program for the group of midwives I worked with last year.

I am travelling with Dr Kirsten Small, an obstetrician based at Selangor Private Hospital in Nambour. I was asked to bring a woman obstetrician with me this time as the main groups would be all doctors, and Kirsten was an obvious choice. Her role is to cover off the evidence that supports natural birth and to challenge re-thinking the standard obstetric approach to birth, which includes shaves, enemas, lithotomy and episiotomy. Inductions or augmentations are also routine and the caesarean rates are very high.

The first program began yesterday. We were lucky with the unbelievable traffic and actually arrived early, which is considered very bad in Iran. If you are early you clearly have nothing better to be doing, even at 8.15 in the morning! The group was about 40 people, and included some staff from the Ministry of Health as well as the obstetricians. After the opening ceremony, we got down to work.

We began with introductions. Each doctor told us where she was from, how many births they had in their unit and their caesarean rate. It is astonishing to hear how many maternity units have 1000 births per month - almost all were over 600 per month. The caesarean rates they quoted were for emergency surgery and averaged 30 - 40%. I am sure they were not including the elective caesareans in this number as the overall figure I know is around 60%. I think there was some under quoting going on as well.

Then came agenda setting. This was not an activity they were expecting, but we wanted to know what was important for them to discuss, and we made a list. The usual topics were there, including legal issues and changing women’s attitudes. It was clear they felt they were only doing what the woman wanted - a quick and painless surgical birth just like everyone else has experienced!

We ploughed on to explore the outcomes they wanted from births (healthy mother, healthy baby, low mortality, low morbidity, increased self esteem for women etc) and then I asked them to list the methods they used to assess whether these outcomes were being achieved. This was difficult for them as they hadn’t really thought beyond the statistical collection that is compiled and the feedback from women at the 7 and 42 days post natal visit.

Kirsten then presented a lovely slide presentation on natural birth, using some of Lynne Staff’s birth photos and some of her own. There were gasps at the end when one of Kirsten’s beautiful slides appeared on screen of a mother breastfeeding her baby, sitting on a birth stool, with the cord still attached and a second twin emerging by the breech.

Following this came a small group exercise to explore the role of the obstetrician, midwife and mother in achieving a natural birth. There was confusion all round as I used the colours of the rainbow to form small groups (”what is ‘violet’?, what colour is indigo?” etc) but eventually the group work got underway and ideas were accumulated.

The pelvis exercise was tackled after lunch. A large Persian rug (of course!) was rolled out on the floor and I was able to persuade most of the group to join me in exploring how the pelvis works. They were shy and I must say is wasn’t easy with everyone in full hijab, and with long coats over their clothes. Still, the message was conveyed and they were interested to discover how positioning can prevent or solve potential problems.

To consolidate the message I showed the second part of “Giving Birth, Being Born” which describes the cardinal movements of the baby using animation, the benefits of upright postures for labour and birth using clips from actual labours and clearly shows women giving birth without shaves, enemas and drugs.

It was a full day and we were all exhausted at the end. We battled back to our hotel through unbelievable traffic chaos (think dodgem cars writ large with stray pedestrians in amongst the moving mass and you’ll get the idea) and set about fine tuning today’s session.

At the start of the day we were confronted by a large mass of black shrouded women, looking grumpy and unwilling to be there. By the end of the day there were some smiles and nods happening and I could see a distinct softening in their attitudes and approach. Today we’ll concentrate on more of the practical measures they can use and tackle keeping women off the bed. One comment yesterday was that if women got off the bed and walked around in labour there would be “no way to control them”!

We are also hoping to see the labour rooms in the hospital toady as preparation for a planned activity for day three. We’ll take some photos and I will include them in my next report.

This weekend I am in Cairns, presenting an Active Birth workshop. The group is lively and fun, with representatives from Cairns Base Hospital and others in the extended region.

An interesting theme emerged yesterday. We were talking about how it is often the motivated who attend these workshops, and how important it is to give those who are keen to support women through natural births a regular dose of encouragement and enthusiasm. Unless this happens there is a real chance they will burn out, get fed up with battling rigid policies in their hospitals and leave midwifery altogether. This has happened in many places and I have often had these stories related to me. Many midwives have also said to me that an Active Birth workshop was a pivotal pointing their decision to stay on and keep working for change.

One of the participants commented that it was notable that none of the core midwives at the local hospital was in the group. Many of the team midwives had made the effort to come on a precious weekend, but none of the senior midwives in the unit were present. This is a shame as the midwives in this workshop group have many issues with current policies in a number of areas and a general discussion on these topics would have been useful. Instead we have talked about how the rank and file midwives can approach their senior staff to stimulate reviews of outdated policies etc. It is hard for junior staff to approach their managers and seniors, yet it is the newer midwives, often fresh out of midwifery school, who are most up to date with current research and practice.

At the end of the day, changing a health care system is difficult, whether at a very local level or across a broader region. It is a huge beast that is slow to rouse, often affected by entrenched habits and routines and change is hard to stimulate. Midwives have the advantage of working with healthy women who are quite capable of taking an active role in their own care, and stating their own needs (if given the opportunity). I believe the best way for midwives to stay focused, satisfied and rewarded is to work one woman at a time, listening to her desires, creating her special birth place and enabling a very individual event to take place. It will be women she serves that offer the best rewards for midwives and every woman who has a natural birth has an impact on the wide health care system.

We’ll have more to explore today as we look at very practical measures for keeping birth normal.

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

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

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

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

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

Over the last three days I have been presenting the Essential Educator workshop in Sydney. We had a terrific time exploring the possibilities of prenatal education and the practicalities of facilitating programs for parents.

The group were from all over - UK, Japan, Melbourne, Brisbane, Canberra, rural areas and of course, Sydney. It was a lovely mix of experienced and new recruits and we all had a lot of fun working through a variety of teaching strategies, based on the Essential Educator kit we have developed.

I’ll be scheduling more of these workshops next year - one in the UK in April and others in Australia from mid-year. It seems unreal to be planning workshops so far ahead, but the year is racing by.

Next weekend I am in Cairns for an Active Birth workshop and the midwife from the UK is also attending that program. She works in a midwifery led unit near Sheffield and will be using all these ideas in her work when she returns home from a year long holiday in sunny Australia.

I am also putting together an Active Birth schedule for next year and will be happy to accommodate any requests from readers. As I have several overseas trips in the planning stages as well, even an overseas workshop could probably be squeezed into the calendar. Just send me an email and we can talk dates: andrea@birthinternational.com

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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.