Articles by Month: March 2007

Future Birth Tour 2007

The “Future Birth - exploring new paths to birth” tour has been a huge success. The tour took in six major cities around Australia in eight days - a real travelling circus - and was universally praised on all fronts. The four fabulous speakers provided a wonderful array of ideas, insights and experience that werre appreciated by everyone who attended. Underpinning their presentations was an obvious and deep commitment to women, babies and health and a passion for midwifery that was engaging and inspiring. You can tell that I had a wonderful time, can’t you?

Our tour group: Andrea, Marcos, Polly, Sandy and Sarah

Polly Ferguson opened the day with a clear description of the All Wales Pathway for Normal Birth. This clinical care plan, agreed between all midwives and doctors in Wales, has been responsible for lowering intervention rates, reducing caesarean births and promoting midwifery care through their country. After a long (and exhausting) process of collaboration and discussion, the basic fundamentals of normal birth were agreed and are now applied to all women who want to have a normal birth. In a neat turnaround, midwives assume that a woman who asks to have a normal birth will be offered care described in the pathway, and they will not discuss any alternatives unless there is clearly a medical problem developing in the pregnancy and labour. Recording the woman’s progress is simple - all the midwife needs to do is initial and date each step along the printed Pathway, and make a mark on the partogram during labour - no notes need to be written unless there is a need to explain a deviation. It is a simple strategy that assumes normality from the start, reduces the paperwork during labour and enables the midwife to be much more “with woman”.

Polly will be sending me the evidence underpinning the Pathway that was hammered out during discussion between all stakeholders. Once I receive this, I will upload the Pathway and the evidence onto our website.

In her closing remarks, Polly described how most midwives are “up in the stands” shouting complaints, instructions and sometimes abuse to those playing on the field below. She pointed out that this wasn’t much help and that it was much more fun to be “on the field”, tkaing part in the game. She encouraged everyone to “get their boots on and start playing” - a message that will be taken up by many who will now consider using the Pathway in their own units.

Dr Marcos Dias offered us a rare glimpse into the workings of the maternity health care system in Latin America. He described typical birth outcomes in many of the countries in this region, and what is being done to provide a more humanised experience for women. Marcos is passionate about public health (rare for am obstetrician) and he has committed himself to improving birth outcomes, especially in Brazil. He built the first birth centre in Brazil, in Rio de Janeiro, where midwives are responsible for the care of labouring women. He told us how he had to go to court three times to fight off the doctors (“mothers will die, babies will die”) before it was allowed to open.

Marcos Dias presenting his paper at the Brisbane seminar.

Midwifery as we know it is a very new profession in Brazil, as most women have either obstetric care in the cities, or are assisted by a traditional birth attendant in the poorer rural areas. Marcos is a founding member of REHUNA, the organisation for the humanisation of birth, and was involved in the first two birth conferences on this theme held in Brazil. The first of these was in Fortaleza in 2000 (where I first met him) and then again in 2005 in Rio de Janeiro. There will be a similar event in October 2008, again in Rio, and once more it is expected that around 2,000 people will attend.

Everyone was deeply impressed by this modest man, who is totally committed to women’s health and who is making bold moves to shake up the system through his work as an advisor to the Brazilian Minister of Health. His paper will be on the website very soon.

Dr Sarah Buckley is an Australian GP and mother of four home birthed children who is also a passionate advocate for better birth. Her main concern is the health and well-being of the baby and the emotional, psychological and physical health of the birthing woman. She spends much of her time checking the evidence and scouring the research, assembling an awesome array of scientific data to support her call for undisturbed, ecstatic birth. Her paper was universally acclaimed for its insights and detail, and participants went away with a detailed outline of the impact that birthing practices have on the delicate balance of hormones that are necessary for a successful birth.

Her paper will also be on the website soon, and her book Gentle Birth, Gentle Mothering is a wonderful collection of her writings on this subject, gathered from the many publications to which she contributes regularly.

Sandy Kirkman’s appearance on the program was eagerly anticipated by those who had heard her on the last tour. Sandy is a brilliant speaker, using a hilarious blend of humour and stories to illustrate her message (on this tour) about gender influences on communication. She explained how the different ways that men and women behave and the way they use language can lead to all sorts of misunderstandings, sometimes with unfortunate results.

This can be a particular problem between midwives and obstetricians, who view the world from different gender paradigms. She left us all with some simple instructions that could assist in better collaboration and co-operation, especially in labour ward settings. The first was “never ask an obstetrician for help unless you want him to fix the situation” and “avoid using the word “yes” as a conversation encourager - be direct and simple in your communication with men”. She had some side-splitingly funny stories to illustrate her observations, which left us all uplifted at the end of the day.

Everyone went home laughing, with a broad smile on their face - a rare achievement at a seminar (except ours, of course!).

I am now thinking about the next event, due in two years.....

Posted by andrea at 04:25 PM

Training midwives and TBAs in Uganda

Jill Moloney writes about midwifery training in Uganda:

The students are about to take their final exams and hopefully they’ll be able to bring some positive changes to the maternity ward. I met with the “Matron”of the hospital today and have started to line up further training for the staff already working on the ward (again it will entail supporting the normal physiology of labour). The District Department of Health is also co-operating in releasing midwives from the health units for the same training, which will then (hopefully, all going to plan)lead into the next phase of creating “mother-friendly”birthing environments.

Then I’m hoping to introduce Kangaroo Mother Care” - the tutors of the midwifery school seem to be up for it so I hope the hospital and health unit staff are, too, and particularly the funding bodies.

Here are some more images from Uganda:

This Elder wanted to take “Africane”home with her. Some other community members came to see the doll and also posed for the photo.

Another TBA holding “Africane”taken in front of our office -the huts behind were constructed by the people internally displaced by war.

This photo shows some birth attendants practising abdominal palpation - the man is obviously playing the role of the pregnant woman and it caused much laughter in the group. The fetal doll is under the “skirt” and so can’t be seen.

Posted by andrea at 02:02 PM

Childbirth education in Uganda

Many of you will have been following the adventures of Jill Moloney, the Australian midwife who works in developing countries where she spreads the word about physiological birth. Recently we sent her some teaching aids for use in the midwifery training in northern Uganda. Jill has sent me some pictures - I am glad the doll is one of our black models! It is going to be loved to pieces!

Here are some extracts from her email, and also her description of the photos:

G'day Andrea and Staff of Birth International,

I just wanted to thank you for the charts you included in the shipment of fetal doll and pelvis sets you sent to us in Uganda in December 2006. We finally received them here in Kalongo (in the North of the country) at the end of last week and they are already a huge hit in our location. I had one brown doll in my bag as I was walking through the town on Friday and took it out when I met a staff member who I thought would be interested in seeing it. She was delighted and couldn't believe the likeness to a newborn baby. When she finished inspecting it, I turned to go on my way, only to find that there was a huge crowd of people behind me, all eager to inspect the doll for themselves. S/he was passed from elders to grown men and women, teenagers and young children and they all were smiling and wishing for one of their own!!

I have my initial sessions with the staff of the midwifery school and regional hospital on Friday 2nd March and have delivered two doll and pelvis sets and the charts you sent to the midwifery school today. The head teacher and two other tutors were there and they were excited and absolutely thrilled with the quality. They are looking forward to our up-coming sessions about normal physiology of labour and making their services more woman-friendly.

These two men who wanted to see the fetal doll and they played with it for some time. They are sitting in the corner of a restaurant and yelled out to me as I walked past with “Africane” (pronounced Africarn) as the doll has been Christened!

This photo is of Florence, one of our recent recruits in the Public Health Programme. She assists Josephine, our midwife and Traditional Birth Attendant Supervisor, and she is pictured with a TBA who attended a workshop about supporting normal physiology in labour. This part of the workshop was about supporting women in a position of comfort and she demonstrates supporting a squatting position when the mother is pushing, but from a standing start.

Here is Josephine supervising TBAs in the workshop they are “practising” their old skills of supporting women to give birth in a squatting or kneeling position.

Josephine is teaching TBAs about the mobility of the pelvis (lesson taken from your “Empowering Women”book). I am in the photo and have my back to most of the TBAs as I have trousers on and it made it easier for them to see where to place their hands during this exercise.

This photo is taken further into the pelvic mobility part of the workshop where the TBAs are feeling the movement of the ischial tuberosities.

Posted by andrea at 01:42 PM

Moving on

It is time to get back on the plane for the trip home. This has been a fascinating tour of duty - each of the workshops that I have presented have been completely different: even though the subject was always “active birth”, the composition of each group varied considerably.

The first program in Hull was for the community doula project and the group was mainly made up of volunteer doulas who will be matched up with vulnerable women at risk to support them through their pregnancy, birth and postnatal period. Although some had given birth themselves, they basically had very little knowledge of childbirth, so I had to balance the content to meet their needs as well as the interests of the midwives who were also in the group. Working with non-professionals always presents a different set of challenges and keeps me on my toes!

The next group was in Halifax/Huddersfield, and were midwives from two different hospitals with very different practices. They are in the process of merging campuses, which also involves establishing a new birth centre program. The two groups were a bit suspicious of each other, having heard plenty of “rumours” about each other’s practices. In the end, some new relationships were forged and new understandings emerged - as one said at the end “we all have the same problems, really”. I was very pleased with how this group worked - they went away energised and ready to try new ideas, with a firm commitment to women and their needs above all.

From there I went to Limerick to work with the second year students in the midwifery course. This has become a regular event for me, and it is always stimulating to be around students. Their main gripe was that they were not seeing the kind of care we were exploring in their practical placements - a few had seen birth off the bed, for example, but most were seeing the usual ritualised “active management”style of birth. This was disappointing, as I have done a number of workshops for midwives working in the local hospitals (but not all staff) so I suggested they keep asking the questions that students are entitled to ask - “is this really necessary?”, “is there some evidence you can point me to, to support this practice?” etc. I’ll be back there in 2008 for the next batch of students, so we will see what they have to say about progress.

Next was the Croatian trip, which you can read about above. I am hoping to go back there as well, perhaps to work with the midwives. I would love to be able to give them some more help.

My final workshop was in Wales, on the theme of “The Essential Educator”. The Welsh have really taken to the teaching kits I have developed and have ordered a number of them. This program was for the educators who will be using them, to take them through some of the activities, explain how to make the best use of the materials the kits contains and provide some additional training on group work etc. I’ll be back there later this year as well, as they are buying some more kits and will want further training for their staff.

Wales seems to be the one place in the UK where birth is going ahead in a positive way. Their “Pathway for Normal Birth” record keeping system has been instrumental in reducing midwives’ writing time and freed them up to spend more time “with women”. Their caesarean birth rate is not as high as elsewhere and they have developed some great 1 - 2 -1 midwifery programs in the community and through birth centres. Much of this has been driven by Polly Ferguson, the dynamic and passionate Midwifery Advisor to the Welsh Assembly - you can meet her and get your own copy of the Pathway documents at the Future Birth event in a few weeks. We can learn a lot from the Welsh!

Not a bad series of workshops for a rushed 2 week period! Time for home now, to get ready for the Future Birth tour and make plans for my next foray overseas, which looks like being another trip to Iran, in May.

Posted by andrea at 04:29 PM

RODA: Parents in Action

At the end of the two days, I felt as frustrated as my group members. I had no quick fixes I could offer, as many of the roots of these problems lie in the remnants of the totalitarian regime the people have lived under in the past. These repressive regimes have left many people feeling helpless, believing can’t do anything to change conditions.

This visit was sponsored and hosted by a wonderful group of women who have formed RODA - Roditelji u akciji (“Parents in Action”). They are refusing to buckle under and have been fighting for many years to influence change. Their conversations with doctors regarding birth practices have met with little success (like doctors everywhere, they will resist change to the bitter end) but they have had some rewards for their efforts, especially with breastfeeding.

The city authorities in Zagreb have given them access to rooms in a city building for a very nominal rent. It was in desperate need of renovation, so they got stuck into it and have produced some stylish and comfortable results. This space is used for meetings, groups, classes and as a general drop in centre for pregnant women and new mothers.

Some of the core members of the RODA group outside their headquarters: (L to R) Anita, Vedrana, myself and Saradadevii.

Photos showing the condition of the room before renovation.

Transformed into a very comfortable space, this is RODA’s “nest”.

Breastfeeding is a topic they have been pursuing recently, especially the problems associated with the routine early separation of mothers and babies in the maternity hospitals. With the help of some supporters and a friendly billboard company, they have managed to have these huge signs erected in many places around the city, often in very eye-catching places. The message is about the non separation of mothers and babies and translates loosely to “mothers need their babies and babies need their mothers”.

We had some serious fun thinking about billboards that would highlight the plight of women during labour. Getting a camera into a labour room would be very difficult, but with the increasing availability of mobile phones with inbuilt cameras perhaps it will not be so hard. Pictures tell a thousand words, and I explained how the images published by Suzanne Arms of labour rooms in the US in the 1970s were a major breakthrough in exposing the terrible practices being inflicted on women there at that time.

Croatian women also need better access to good information about childbirth and RODA are beginning to work on setting up some prenatal classes in the community. Hospital based programs are part of the coercion process and offer few options and no choices. I am hoping we can work together to devise some appropriate programs that will help inform and prepare women for birth and provide some strategies for getting what they need during labour.

The requirement to adopt EU standards for women’s health, patient’s rights, non-discrimination and human rights will also provide useful tools for RODA. There is no doubt in my mind that improving conditions overall must be seen as feminist and human rights issues, and that this might offer the best change of systemic change.

I can imagine a billboard with a picture of labouring women, lying in a row, with no privacy, little dignity, nothing of their own around them and no company, over a slogan that says “look at this - we wouldn’t do this to animals, why are we doing it to our women?”

Posted by andrea at 06:28 AM

Midwifery in Croatia

There were some midwives in this group who told their side of the story as well. They too were frustrated and sometimes traumatised by what goes on, and some had taken steps to find another way. One group, from Varazdin (north of Zagreb) had evolved a good working relationship with a young Obstetrician and they were providing midwifery care that was humane and more woman centred. Another group on the coast were proud of their hospital where water births and birth stools were commonly used. Some of these midwives had spent time in Amsterdam learning how to facilitate water birth and midwifery care and they were keen to show others in Croatia how this could be done.

Midwifery training in Croatia is very basic. Most go straight from school at age 15 - 16 into a three year course in nursing/midwifery and leave at 18 -19 to take up jobs in hospitals. There they act as handmaidens to the doctors as they have no skills in managing pregnancy or birth on their own. They are not even taught how to undertake a vaginal examination, and have very little practical experience before they graduate. Their final year, which is spent in hospital, is a year of observation, not practical skills training or supervised learnng.

It is illegal for midwives to assist at home births, which is probably wise in these circumstances. Older midwives with many years of hospital based experience may be capable of assisting at a home birth, but it would entail risk for her and the mother, which may be unacceptable.

Croatia will be joining the European Union soon. Once this happens they will be required to comply with many EU Directives. Some of these will benefit midwives and birthing women - the laws relating to discrimination and equal access and equity will apply as well as basic human rights. Midwifery training will have to comply with that in other EU countries and midwives who have worked in other countries will have to be allowed to work in Croatia. This might bring some much needed educational opportunities for Croatian midwives, who now have no chance of learning from seeing different ways of assisting births.

The Croatian Midwives Association is struggling to make any political headway with the hospitals or the Ministry of Health and there is a distinct lack of enthusiasm for change of any sort if it involves the doctors. Once the borders between Croatia nd its neighbours come down and travel becomes easier and more popular, it will open people’s eyes and stimulate much needed change in many areas, For women giving birth in Croatia today, these changes cannot come fast enough.

Here are some scenes from the workshop, held in a gymnasium in Zagreb.

Posted by andrea at 05:56 AM

Giving birth in Croatia

Last weekend I was in Croatia as the guest of RODA - Roditelji u akciji (“Parents in Action”).

On the Friday night I addressed a public meeting that was well attended by pregnant couples, and on the weekend I facilitated a workshop for 40 women, including a number of midwives, some pregnant women and a number of members of RODA. Everyone was keen to learn what they could do to improve the birth experiences of women in Croatia and to formulate some plans for achieving change.

I began the workshop by asking everyone to introduce themselves and tell a little of their history and involvement in the birth scene. It took 1 ½ hours and became a kind of group therapy. Story after story tumbled out about their births, most of which were horrendous and traumatic. By the end we were all exhausted with emotion and overwhelmed by the sheer magnitude of the suffering of Croatian women during birth. It was sad, and the pain was obvious, but the passion for doing something about it was palpable and impressive.

In summing up the birth scene in Croatia, I would have to say that it sounds like torture for the women. Pregnancy care is also characterised by demeaning and humiliating experiences. Many of the aspects of maternity “care” being inflicted are outdated, without scientific foundation and could, in some cases, be considered physically, emotionally or psychologically dangerous.

Here are some of the facts I gathered from these women, many of who had given birth once but were reluctant to go through the process again (unless they could travel to another country).

Throughout all of this ordeal, the mother is often treated rudely and controlled through both bare threats to her baby and innuendo. There are few avenues for women to find out any information and choice is non-existent for most.

Listening to story after story revealed the depth of some women’s pain and suffering and was a humbling experience. The birth rate is falling in Croatia and it is clear that many women never want to repeat the experience and risk suffering further emotional and physical trauma.

There were women who had heard of the prospects in Croatian hospitals and had decided to go elsewhere. A number of women in this group had gone to Austria, Germany or the Netherlands to get a better chance of a normal birth, and many had succeeded. One women had decided to birth her second baby alone at home after a successful first birth in The Netherlands, because she didn’t want to risk herself or her baby in the local hospital in Zagreb.

It is a pretty bleak picture, but one I gather is common throughout many eastern European countries.

Posted by andrea at 09:39 PM