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.

Preparing for Birth: Mothers and Preparing for Birth: Fathers are the best selling books on childbirth in Australia.  Almost 30,000 copies are sold each year, distributed mainly by hosptials as part of their preparation for birth and parenthood programs. They make a stylish and professional addition to the classes and ensure that parents get information they need to make informed decisions about pregnnacy, labour birth and the early paost-natal period.

Last year I was asked by Nanako Ona of the Japanese Birthing Association and the Birth-Sense Institute in Tokyo for permission to have these books translated into Japanese, for sale and distribution through the network of  classes she oversees in Japan.  As I have worked with Nanako before and visited Japan to present workshops for her (with the support of the Australian Embassy in Japan), I was very excited by the proposal. We have worked for a year to get the translation done, through my Japanese translater Yoko Yuille, and the results look terrific (even if I can’t read a word of them!). They’ve used all the original illustrations and we’ve only changed the text where local conditions are different, for example with diets, drug use, labour and birth procedures etc.

Some years ago the Mothers booklet was translated into Thai and it sells there through bookshops, with the proceeds going to the Birth and Breastfeeding Foundation of Thailand.  I am also hoping that the Mothers booklet might be translated into Farsi as well, for use in Iran.

If anyone wants a copy of the Japanese version for use with a specific client in Australia, I have some available.  Send me an email……

As mentioned in  my previous entry, childbirth education in Iran is in its infancy. The first classes only began about 2 years ago, and were modelled on a program an Iranian midwife had used in France. This is fine as far as it goes, but it has huge gaps, especially in the area of labour and birth.

Given that birth in Iran is totally interventionist, it is surprising that the obstetricians have been able to continue on this path without any questioning or opposition, especially from women.  If the whole subject of labour and birth management is omitted from even the few classes that now exist, then this state of affairs will continue.

Women need information about a whole array of topics, from hospital routines, to the drugs, obstetric procedures, complications and caesareans that are so prevalent.  At present, the prenatal program contains a short lecture on the stages of labour, but nothing about how the birth will be managed.

The training program that had been developed to provide educators with the necessary skills to facilitate prenatal programs is also very sketchy.  I have now sent them copies of the training course program and curriculum that we used with our Graduate Diploma in Childbirth Education. There are elements within it that may be useful as a starting point for developing an appropriate course in Iran.  I am hoping that they will set up a distance education package, adminstered centrally, because with such a large country, this would provide the best access for student educators.  It would also help maintain consistency and quality, something that is difficult to manage when the training is decentralised through many universities as now happens.

During the workshop, we again tried out a number of teaching stragtegies and activities that can be used in parent education programs. Although these were enjoyed by the midwives at the workshop, I suspect that they didn’t really “get it” in terms of using these in an actual class with pregnant women - they seemed to focus more on their traditional teaching methods which are all didactic in the style of most university education.  This is another reason why I believe a centrally orgnaised training program will be more effective and innovative - if the key trainers do “get it” (and there are some switched on women in Iran) they will ensure that they train educators to provide classes that are fun and interactive and not a series of lectures or school-like lessons.

“What’s labour like” (above and below) always generates lively discussion.  I was particualrly interested to see how this activity was interpreted as most of the group only have a theoretical knowledge of normal physiological birth.

We also had fun with “graffiti sheets” on changes in pregnancy  (below).

We also had some very interesting disucssion about “the breathing” and the “relaxation”, as they have been using ideas that are rather out of date, and frankly useless in the Iranian context.  As I pointed out, it is waste of time teaching women in how to “breathe” and “relax” in labour when they will be lying on a bed trying to cope with an array of humiliating obstetric procedures.  No amount of training or practise will work in the face of ongoing physical abuse resulting from serial vaginal examinations from a parade of unkown junior doctors and registrars.  To lead women to believe that the training will make the birth less painful is also dishonest.  A solid course in how to say “NO!” might be of better value.

I will be interested to get some feedback from the team in Iran and to hear their thoughts on the training course I am suggesting.  Women in Iran deserve a better deal during pregnancy and labour and I believe that better education will be an important component in bringing about the necessary changes.

I have just returned from another mission to Iran, where I am working on a project to improve the childbirth practices for women and babies for the Ministry of Health and Medical Education. This has been my third trip, funded through the UNFPA, and it is pleasing to see that some improvements are now in place and that efforts are being made to take these further.

The main effort has focused on the establishment of eight centres where normal births can occur. These are located in Tehran (2 centres) and 6 in regional cities around the country, including Mashad, Gorgon and Tabriz. Each has been provided with some basic equipment that would be found in a typical birth centre such as a bath, access to a toilet and shower, floor mats and birth balls, some privacy and more space.

In Iran, obstetricians are totally in charge of childbirth and midwives play a subservient role, acting as obstetric nurses. It was encouraging to have several obstetricians tell me of the great success they are having with physiologic birth in these new centres. It certainly helps that virtually all obstetricians are women in this Muslim country, but also sad that many have chosen caesarean births for themselves, due to the inhuman conditions that prevail in most hospitals.

One of the main goals of this visit was to help set up a program for training childbirth educators in Iran. I feel this aspect of my visit has been less successful than I hoped, for a variety of reasons. It is clear that there is no concept of how a training course should be established and the role of the educator is not clearly defined or even understood. There is a fledgling program in place but this needs to be completely re-vamped so that it reflects adult education principles, incorporates appropriate subject matter and enables educators to develop presentation, communication and counselling skills.

Each of the new centres had set up a program of prenatal education for pregnant women. This is a first - until recently there had been no formal education available for expectant parents. The program that is in place covers the basics of pregnancy and post natal care but is very inadequate when it comes to labour and birth. Women are still not being given any information about the many interventions and medical procedures they will be routinely subjected to in hospital. There are no detailed discussions on shaving, enemas, rupture of membranes, oxytocic drips, forceps, vacuum, episiotomy and caesarean birth. Discussion about the other routines that are carried out, such as no access for a companion, restriction of fluids in labour, hourly vaginal examinations, labouring on the bed, the use of pethidine and nitrous oxide for pain and the routine separation of mother and baby following birth also need to be included.

For many women, giving birth in Iran represents a horrific experience where their human rights are disregarded and they are routinely subjected to humiliating, embarrassing and unnecessary procedure. Many will opt for caesarean birth to avoid these indignities. The Ministry of Health is keen to change this, but it will take a concerted effort on several fronts to improve the birth experiences for women.

I’ve been asked to make a number of recommendations.

First, I have suggested that those hospitals and obstetricians who have embraced normal physiologic birth should be publicised as widely as possible, in recognition of their work and also to alert women that alternatives are now starting to appear.

Secondly, I have recommended that a new course be developed that focuses solely on midwifery. At present the basic nursing course and the subsequent midwifery degrees are too broad, requiring graduates to be competent in areas outside the accepted scope of midwifery such as paediatrics, gynaecology and women’s health. Many of the midwifery courses are taught in part by obstetricians and a standard obstetric text is the basic reference. This is unsatisfactory and has left midwives feeling unable (and unwilling) to take responsibility for the care of women during pregnancy and birth.

The whole area of childbirth education needs a re-think. A clear vision of its purpose, objectives and structure needs to be prepared and a program developed that is separate from mainstream midwifery, preferably administered by a dedicated team of master trainers. I’ll be working with they key personnel within the Ministry of Health on these issues.

Overall, this has been an interesting mission. I was left feeling frustrated by the educator’s workshop I presented, but heartened by my program for the obstetricians. The midwives workshop was mixed - they need a lot of support and encouragement to fully embrace their role as primary health care professionals.

As ever, the Iranians have been generous and gracious hosts. I have been very well cared for (through boundless hospitality) and I feel I have made some very dear friends over the past few years. I hope that I can continue to work with these people as they make further progress in the future.