Saturday, February 23, 2008


[Photo: My niece Laura and her baby Elie, my husband Noel, and me, Joy]



THE OLD GREY MARE SHE AIN'T WHAT SHE USED TO BE

Today I am being very practical, thinking about the weariness I feel after being out all night. This old grey 'mere' (French for 'mother') used to work night shifts in a hospital - nowadays she likes to spend the whole night in bed. And when in bed she prefers to sleep - something else that has become more elusive with the progressive whitening of the hair.

The other day I received a call at midnight, and headed out to the home in the hills. Jane (not her real name) was very pleased to be in labour, and was walking around and enjoying her early labour. After a while I lay down, but did not sleep. Labour became stronger from about four, and Jane gave birth to a beautiful healthy boy at about 6.30 in the morning. I went home and spent a few hours in bed before getting on with what I could of the day's work.

Was I really stronger 20 years ago, was it really any easier then, or am I just more willing to be honest about how I feel now? I have a memory of those night shifts in the maternity wards at the Women's and St George's Hospital in the 80s and 90s: fighting off sleep in the wee hours; the horrible exhaustion that I often felt as I collapsed into bed in the morning; the legs and feet that stayed cold for what seemed like hours. The interruption to the body's usual diurnal processes brought on jet lag for a few days every week.

Working through the night is never easy, yet it was a choice I made while our children were growing up. It gave me the option of being at home when they returned from school, and it seemed the best option at the time. I enjoyed the uncomplicated quietness of hospital life in the night. The only people there were those who needed to be there. There were no 'politics'. Everyone had a job to do, and got on with that job. Over time I developed confidence in working with the natural processes in birth, and as I learnt to be 'with woman' I became assured of my midwife identity.

Since I have been working independently I have truly appreciated the fact that I am no longer working night shifts. Even if every woman booked were to call me out at night it would only be a few nights in the month. I know that night is a time when many women labour spontaneously, and I accept the need to be called out at night.

I believe that the best way midwives can provide appropriate primary maternity care is to take caseloads - to enable women to face childbirth in partnership with a known and trusted midwife. There is no easy way around the issue of sleepless nights on the job - each midwife needs to find the best and most sustainable way she can do it. The world of managed care in obstetrics, in which labours are induced at a time that is considered convenient is not in the best interests of mother or baby. There is no safer way for most women than to labour spontaneously.

I do not ask women to delay calling me so that I can get more sleep. My commitment to each woman means that she is the one who determines the best time to invite me to be with her. I like to have a chat with women in the days before they labour, so that they are confident in their knowledge of their bodies, and confident in their relationship with me.

In recognising the importance of a one-to-one midwifery partnership, I need to balance that with the woman's need to be sure that her midwife can be replaced if that becomes necessary. It's a fine balance - one that midwives are addressing in group practices and specific backup arrangements.

Sunday, February 17, 2008

STUBBORN

‘Stubborn’ is the word that settles in my mind as I reflect on this mother who gave birth, who I will call Sally (not her real name). Sally was uniquely, beautifully, proudly, strongly, and wonderfully stubborn. She is a mother, and in her mother-role she is stubborn. She has three young children, born overseas, and a new baby born at home in Melbourne this week. Sally grew up in USA, and her husband grew up here.

Sally stubbornly prepared for this birth, finding the people and the type of care that she wanted. She stubbornly ignored the custom of her community as she made her plans. She stubbornly informed me of what she wanted from her midwife. I don’t think she really believed, until after the birth, that what she wanted was the same as what I wanted.

Birthing, the quintessential female state, transcends culture: Sally’s culture, and my culture. That’s why as her midwife I can know, without doubt, how to be ‘with woman’, no matter what her, or my, culture, religion, or place in a society.

Sally’s knowledge, upon which she confidently built her birth plan had been set down in the experiences she had had in her birthings. She had gathered the best of women’s knowledge over the past seven years. She knew what was good because she had tried it and it had worked for her. She knew what was not good from experiences of being disturbed and distracted in labour, being unable to progress as her time of surrender drew near. She understood, and planned to avoid, separation anxiety that had come when her new baby was taken from her for hospital procedures like weighing. Her stories of the three previous births included signing herself and her baby out of the hospital’s care, stubbornly demanding her own place as mother of these children.

I think of Sally as a she-wolf: independent and confident in her own role, and keeping any unwelcome intruders at bay.

Sally prepared her birth plan with the same stubborn authoritative spirit that I saw in her birthing. The memories of that birthing and the subsequent visits I have made to their home are fresh in my mind, and in writing this memoir I want to honour this strong woman. But rather than writing what I experienced, Sally has given me permission to share excerpts from her birth plan, and I know these statements will tell something of Sally’s story. She had written:

“This baby was planned and made with love; the birth is very much an expression of the culmination of our love for each other. It is very meaningful to us that our love can be so powerful as to bring a new person into this world. Please respect our need to make this birth an intimate and spiritual experience by reading through our birth plan. …

“I want to have a baby and that’s why I’m pregnant and going through the journey of labour and birth. Please let me do my job as a mother - just being present is supportive and it may be the only role I need from my support person or midwife. If a further role becomes needed, please act. …

“I trust in my midwife to follow a non-interventionist birthing approach as we’ve discussed. In the event that another midwife or doctor is present at the birth, please note that I don’t want my baby pulled out: let my body birth the baby. I also don’t want the cord yanked: I want to give my body the benefit of the doubt that it will birth the placenta without intervention. Please don’t administer artificial hormones without justification. I will cut the cord when I’m ready: please don’t clamp the cord until then. Unless needed don’t suction the baby’s mouth: let the baby learn its own body. Establishing breast feeding is a priority for me.

“After birth any separation between me and my baby can be stressful. Please keep this in mind, when wanting to examine and weigh the baby.”

Sally’s plan was to give birth: “Please let me do my job as a mother”. Her expectation of me and my apprentice midwife was that we would be with her, and not interrupt or interfere without valid reason. The time we had spent together prior to the birth, learning how to listen and respond to each other, enabled the partnership between woman and midwife to function well at the time of birthing.

Saturday, February 09, 2008

THERE'S NO MILK LIKE MUM'S MILK

There’s no milk so uniquely and beautifully right for a baby as his mother’s own milk. Yet we so readily find reasons to undervalue the breastfeeding bond.

There’s no way so uniquely and beautifully right to transfer the milk from mother to child than the simple act of nursing at the mother’s breast. Yet, we so readily reach for gadgets and concoctions that approximate breastfeeding in a crude and incomplete way.

Many expectant couples say “we want to breastfeed if we can.” Of course! To my mind the “if” in that statement has the same level of uncertainty as “we want to conceive a baby by our own efforts if we can”, or “we want to breathe unassisted if we can”. The other option is unlikely, and should be avoided if possible.

Yet so many new mothers, with babies only a couple of days old, are convinced that they are unable to meet the needs of their babies, and resort to bottle feeding for some or all feeds. There’s no single reason for failure and discouragement at breastfeeding. Babies are all individuals, with individual strengths and capacities. Mothers are a diverse group, physically, emotionally, and relationally. The relationships each mother has with her partner and her family and friends has great bearing on her ongoing choices and decisions.

We know some of the events that can lead to poor breastfeeding outcomes. These include separation of mother and babe in the early hours and days of life; use of formula, teats and dummies; imposing routines of time or frequency; and giving conflicting advice to new mothers. Yet some mothers who experience some or all of these adverse situations go on to breastfeed beautifully for extended periods, while others who face only the most minor challenges will easily relinquish their breastfeeding relationship.

Sally, who is expecting her second child, told me with pride that she breastfed her little girl Molly for two and a half years. She told me how, when the family moved for six months to a Pacific island, the indigenous grandmothers all congratulated her on breastfeeding Molly who was then a toddler. The grandmothers told her that’s what they had done. Their daughters are not breastfeeding – they have accepted the globalised baby formula sold at the supermarket.

Sally was not well when Molly was born by elective caesarean. Molly developed ‘wet lung’, a serious respiratory distress, and was quickly taken to the nursery where her oxygen levels were monitored in a plastic ‘isolette’ box. Molly’s first feeds were formula. It wasn’t until several days later when Molly began breastfeeding. She had to learn how to suckle from Sally’s breast rather than a firm silicone teat that was thrust over her tongue. Sally had to learn to trust her own intuitive knowledge: her baby’s behaviour, and the tension of her breasts, rather than the number of millilitres in a bottle, in knowing that Molly had had enough.

The challenges that are experienced in breastfeeding are no less complex than any other significant life event. Just as labour and birth can be protected within the healthy natural processes for most women, most mothers and babies are able to make the transition from placental feeding to breast feeding without medical intervention.

Yet the reality of our maternity world today is that most mothers will experience a cocktail of drugs, and a complex set of medical interventions concurrent with giving birth. Most mother-baby bonding will also be complicated by hospital processes and medical interferences. By the end of the first week, when most are at home, some are happy and feeding well, while many are not far from weaning.

Understanding breastfeeding is best done when we consider what the baby feels and thinks about it.

A baby at one week of age, who has only ever suckled from her mother’s breast, is becoming very confident in the process. She knows that when she is hungry she is taken into her mother’s arms, and instinctively seeks the nipple, smells the milk, opens her mouth wide, and sucks strongly. After a short time the milk flows quickly and she has to concentrate to coordinate the work of her tongue, jaw, and swallowing mechanisms. If the milk let down begins and she is not well attached, she will come off and quickly seek a better attachment, knowing that the milk is there.

Another baby, also one week of age, whose experiences have included several different people providing different forms of nourishment in different receptacles may not yet recognise his mother’s breast as the place where his hunger is relieved and he feels exquisitely peaceful. His attempts at the breast have resulted in less than satisfactory feeding, and his mother’s nipples have been squashed, blistered, and grazed, and are very sore. So when this little fellow wakes up hungry it might be his dad or his granny who awkwardly manages a bottle with his mother’s milk in it, while mummy tries valiantly to extract milk from her swollen breasts. The milk doesn’t come, and baby is still hungry, so a bottle of formula is prepared. Baby responds thankfully, and sleeps for three hours.

The challenge to help this mother and baby establish not only breastfeeding, but also restore normal bonding processes, is a much greater one that experienced by his little cousin who has taken every feed from her mother’s breast, and is now thriving on an abundance of the liquid gold.

Monday, February 04, 2008

NEXT GENERATION INDEPENDENT MIDWIVES

Today I experienced an encouraging glimpse into the future of midwifery, as five women sat with me at our kitchen table to plan their transitions from hospital midwifery into autonomous independent practice. This was the first of what I hope will be monthly meetings for the coming six months. Each woman is at a different place in her professional practice journey, and each one will need to find the way from where she is to where she wants to be.

I won't try to record their stories here - they are probably reading this blog, and I know I couldn't do them justice. A couple of these women, both recent graduates, are only a few years younger than I. They have adult children and one has a grandchild and have a wealth of life experience. Two are young - late 20s or early 30s, I'd say, without any children. They are both exceptionally committed to midwifery. Another has an interesting story of studying midwifery by distance education, while living in a remote town in Western Australia. In order to access the practical experience she needed in the course she would drive for five hours to Port Hedland, and work for ten days, before driving home again over roads on which she may not see another vehicle for several hours at a time.

There was a common thread of extra-ordinary lives. As each told her story, I wondered if the next could ‘top’ the previous ones! And they did.

We spent a couple of hours listening to each other, telling birth stories, and getting a feeling for what this group needs to do in order to support each one in her quest. I see myself as a facilitator at present, and I feel privileged to participate.

The plan that we are working on is that each midwife will set out her own plan for professional development, using the Australian College of Midwives MidPlus (2007) program as a guide. Each member will report back to the group on her progress, and any difficulties she is experiencing. These plans will identify specific learning needs, reflective practice, and a sense of accountability to the group. I would like to see each member find a professional mentor from whom she can learn, and to whom she can turn for specific guidance.

I am concerned for midwives who would like to participate, but who are not able to meet face to face with us due to distance and other factors. I would like these people to be able to link in to the dynamics of the group. Although face to face is an ideal way of peer group support, I believe we can use email, Skype, phone, blogs as well as the face to face meetings to achieve our goals. In this way we will create a virtual community that goes way beyond Melbourne’s eastern suburbs. The vision I have is that the ‘remote’ members will be partnered or buddied by one of the members of the face to face group, who will provide a link to the discussion and peer support. The use of webcams with Skype has revolutionised conversations – you can see the person at the other end of the line, and they can see you.

My own interest in this new group has led me to consider the possibility of setting up a course that is offered through a university distance education program. I plan to explore this, and set it as my professional development plan.

One might ask what’s the point of supporting midwives to set up autonomous practice in a society that expects midwives to be obstetric assistants in hospital. That’s a pessimistic outlook.

I have seen a great deal of change and development in midwifery in the past decade, and I believe this form of peer support for professional development and extended practice has a logical place in the profession. I believe there will be increasing numbers of midwives looking for courses which will support their transition from shift work to more woman centred models of midwifery care. I expect that once the ball starts rolling it will gather momentum. This past week has seen the announcement of a large trial at the Royal Women’s Hospital, recording the impact of the introduction of caseloads for midwives. Those midwives will be stepping out of the usual familiar territory of midwifery in this State.

I am optimistic that women are also opening their eyes to protecting and promoting their own healthy natural processes in birth and nurture of the newborn. Women will be increasingly asking for midwives who are expert in working with the natural process, rather than booking into impersonal systems of medical care.

Sure, there’s a lot to be done. But goals will be achieved as we set out taking steps towards them.