Thursday, May 29, 2008

HOW DO WE RECLAIM OUR BODIES?

This question is prominent in my mind as I reflect on my meeting yesterday with a wise woman of the Yorta Yorta people in central Victoria. I won't use her name until she has read what I have written and gives me permission. But what I want to say does not refer uniquely to indigenous women - it's about all women. How do we reclaim our bodies? How do we reclaim our right and privilege, as women, to give birth to our children and to nurture them at our breasts?

We sat together for several hours, and talked. A few years ago there had been a proposal for a birth centre, where indigenous and 'non-i' women could give birth. That proposal was not accepted. There is a centre where indigenous women have prenatal care from midwives and doctors, but that has not improved births for many - the rates of caesarean are high, and women come away from the birthing experience feeling shamed and distanced from their own bodies.

As we chatted a baby woke up and was hungry. Her mother was busy, so I held her close and held the bottle of white stuff. While enjoying the exquisite beauty of the little one in my arms, I could not feel anything other than sadness that she is not able to draw nourishment and warmth from her own mother's body.

The wise woman is an elder, mother, grandmother, aunty, and sister. She has sat on many committees, representing the voices of her people to government and community bodies. She is sad that her people have lost their knowledge of what was done in birth before white people came. She is sad that her daughters are feeling shamed in stead of feeling powerful in giving birth. She is sad that the beautiful breasts of these women are hidden away from their babies.

What could we do? Is there anything that can be done to enable these women to reclaim ownership of their bodies?

We talked about birth centres. Birth centres can be good, with a philosophy of protecting and supporting healthy normal birth, but there is a high rate of transfer for complications. The women who are transferred out to standard obstetric care can feel abandoned.

We talked about the midwives. Some midwives come, and try to provide better and more woman-centred care, but ... They leave after a while.

We talked about surveys, reports, summits, and funding from government departments. The wise woman looked tired, and I felt dispirited - we have been there, done that. Nothing much has changed.

Then we talked about women's business. The older women helping the younger women to give birth, and care for their babies. Spaces where only women could go. A house where they could come and learn to express themselves in arts and crafts, and tell their birth stories. A house where they could feel safe as their labours become stronger, with their sisters and aunties to encourage them. This could be a key to reclaiming their bodies.

The wise woman said she would like women to get together in a women's space and take their shirts off. They could keep their bras on if they wanted to, but you have to start somewhere. This was a new thought to me. I asked her why some of her sisters in the Centre are now having ceremonial dances with their breasts exposed. It's something that they have done to reclaim their culture.

We didn't talk for long about this, because something happened to interrupt our train of thought. But a seed idea had been planted in my mind - is this another key to reclaiming our bodies? What would happen if these women reclaimed their breasts? The older women could lead in ceremony and ritual, and encourage the younger women to cherish their breasts. What would happen if the mothers allowed their babies to find their breasts? What would happen if the mother of this bottle fed baby asked her baby to take her breast once again? I believe it could be done.

When we asked the woman at the BaBs group [http://www.birthingandbabies.info/index.html ] what they valued in the BaBs program, one said, "I can see other mothers breastfeeding. I can see other breasts!"

I believe the only way any woman can improve her chances of avoiding caesareans, epidurals, and other medical management of birth is to take responsibility for their own birthing. I call it Plan A "I intend to give birth under my own power, without drugs or stimulants, and I ask everyone who is with me to respect my plan." The woman herself has to be strong. The wise woman said that in the old days women had to be strong. They had to keep up with the group. There were no short cuts.

We need to return to those old rules for anyone who wants an opportunity to give birth. The non-i women don't need to learn the ceremony of other people groups, but we do all need to claim back the ownership of our bodies.

Thursday, May 22, 2008

Early Learning

Alina
has a daughter, Dina, who is a bright, energetic three year old. I am using their real names, with Alina's permission, as it would be difficult to tell their story without giving some of the detail of this family.

Today, after the birth of Alina's beautiful new baby girl, I noticed Dina looking intently at the placenta in the green plastic kidney dish on the floor. Immediately I understood - she knew about the placenta. So I held up the umbilical cord and Dina looked very pleased. Later, when I was putting away my equipment, Dina was interested in the Laerdal bag and mask resuscitation kit. Dina knew about that too!

Dina and I can't understand each other's language - she speaks fluently in Russian, and in Japanese too I think, but not English. Fortunately, Dina's parents speak English very well.

Having moved to Melbourne a couple of months ago, their priority was to be ready for the birth of this little one. They are living in a furnished unit, and waiting for their boxes to be delivered from the wharf.

As Alina and I talked and prepared for the birth, little Dina was with her mother. One day I loaned Dina a copy of 'Hello Baby' [http://www.capersbookstore.com.au/scripts/shop_item.asp?by=cat&item=2229], and I read it to her in English while Alina translated into Russian. Alina has told me that Dina has had the story read to her every day since!

It would not have been surprising to Dina when she heard her mother's noises - 'singing' an ancient and wordless song that rises and falls with the power of the new baby's progress. Dina understood that her mother was doing something wonderful, important, and very demanding; and that she had her daddy home from work today to look after her. Dina knew that the placenta came after the baby, and was happy to check it out. She had also seen a picture of the midwife's resuscitation equipment in 'Hello Baby'. She knew that her mummy needed to rest with this new baby sister, who was very hungry and needed to take mummy's milk.

Alina called me thismorning to let me know that her labour had begun. Today was 42 weeks - 'post-mature'. We had waited for spontaneous onset of labour, and Alina was confident that her baby was well. She had agreed to go to the hospital tomorrow for monitoring, but that won't be needed now.

Alina was lying on the bed, curled up in that excellent left lateral position that is so good in advanced labour, when I arrived at their house. I did not know what Alina would be expecting from a midwife. Dina had been born in Japan, and it seemed from what Alina told me that she had given birth spontaneously, and that the hospital staff had done their job around her, without really making any connection.

I sensed that she did not have long to go - she was focused and the contractions were powerful. After a while I asked if she was feeling any pressure in her bottom. She wasn't sure, but decided that was possible, so she got up and knelt beside the bed. With the next contraction she felt the baby move. Another and the waters broke. A couple more and she birthed her daughter through the intense pain. Baby was fine, and lay on the mat below her mother until Alina was ready to take her in her arms. It was a beautiful, normal, undisturbed birth. The baby took the breast and stayed there for the next hour or so. The placenta came away about 1o minutes after the birth.

After finishing my paperwork I was enjoying the quiet bliss that seemed to radiate from Alina. I mentioned that there was no hurry to bath the baby - it could be done when they felt like it. They were surprised - it had seemed such an important 'next' in the list of activities last time. "No, it's just a ritual. She's not dirty," I said.

There is so much that is just a ritual in birthing. I want to hold on to the important parts - the freedom to sing the birth song, and to share birth with a three year old, who understands it all so well.

Sunday, May 18, 2008

IS THERE HOPE IN THE BUDGET FOR FEWER CAESAREAN BIRTHS?

Since the federal Treasurer announced the new budget a few days ago, there has been a lot of public comment about the changes to Medicare, and the anticipated exodus from private health insurance. The income threshold for the Medicare levy will rise from $100,000 to $150,000 annually for couples. The Sunday Age today proclaimed on the front page that "Medicare blunder could cost $1.76bn".

I wonder if anyone included in the sums the reduction in claims on the Medicare safety net, whereby uncapped thousands of dollars are shifted from the public purse to the pockets of private obstetricians for every pregnant woman booked with them? I wonder if anyone has assessed the expected reduction in costs when women who would have booked in private obstetric care, thanks to their private health insurance arrangements, move into public maternity care? I wonder if anyone has considered that women and babies may be better off when they give birth in public maternity services?

I am not opposed to private health care per se. If I was sick and needed a stay in hospital for any reason I would prefer a private room to a busy shared 4-bed ward. I would prefer the food at Frances Perry House to that downstairs at the Royal Women's. These preferences seem obvious to my mind. I would prefer to be admitted under a doctor who respected me as a person, and did not treat me as the next case (not necessarily the case in the private-public debate, but we often have confidence in a known doctor over the unknown).

However, the fact is that most women who are having babies in private hospitals are not sick. They are victims of the 'inverse care law' - that those who least need the care receive the most. Obstetricians are medical specialists: surgeons. It is no wonder that they like to perform surgery rather than work in harmony with unpredictable female natural processes. They have no expectation to accept normal birth, whereas midwives are, by definition, expected to protect normal birth.

I have been looking at some of these figures.
There is some evidence that within Victoria's public maternity services efforts are being undertaken to reduce unnecessary intervention into normal birth. The Vic Maternity Services Performance Indicators have been published annually since 2002. The statisticians have looked at what happens to 'standard primipara' - healthy women aged 20 to 34 years, giving birth to their first baby, with no complications prior to the onset of labour. In other words, the mothers who are healthy, young, and least likely to have problems in birth. The rates of Caesarean births for standard primiparae in public and private hospital care are 18.5% and 26%.

Overall Caesarean rates in Victoria have in the past decades been rising by about 2% each year, and are currently around 30% -- 27.7% of all public hospital births, and 37.3% of all private. (Source: Hospital profile of Maternal and Perinatal Data, Victorian Perinatal Data Collection Unit, 2006). The most common reported indication for Caesareans is a previous Caesarean. It is logical that as the number of primary Caesarean births increases, the number of repeat surgeries will also increase.

I now ask the question, how many women who have private health insurance, and have their babies in private hospitals, are likely to move to public hospital care as a result of the provisions of the 2008 Budget? How many Caesarean births will be avoided by this exodus?

Here are some figures to consider:
In 2006 there were over 68,000 births in Victoria: 43,800 public and 24,500 private.
If 20% of the private hospital bookings moved to public, approximately 4,900 women would move from a 37.3% risk of Caesarean surgery (n=1,828) to a 27.7% risk (n=1357). On this calculation 471 women would avoid Caesarean surgery in one year.

That might sound like a small number out of almost 70,000 births in the year, but to those women, it would be hugely significant. And if some of those women who avoided the primary caesarean were giving birth to another child in a couple of years' time, the relative ease of the second vaginal birth should not be forgotten.

I’m not saying that a 27% risk of Caesarean birth for ‘standard primipara’ in the public system is acceptable. By no means! West Gippsland Hospital at Warragul has had a strong focus by midwives and doctors on reducing unnecessary Caesareans, and their rate for the same time (standard primipara, 2006) is less than 10%. But I am saying that 27% risk is preferable to a 37% risk when comparing like with like. Fewer maternal complications in this and subsequent pregnancies; fewer babies needing to be separated from their mothers at birth; fewer women developing postnatal depression; and so on.

Perhaps the changes are going to cost the government a lot of money in revenue, through raising the Medicare levy threshold. It's likely that private health insurance companies will feel the strain of reduced numbers, and reduced premiums paid into their coffers. It's also likely that the private hospitals and obstetricians will object to reduced business. It's possible also that the overcrowding of public maternity hospitals will reach a peak in the coming year. Some public hospitals may actually consider offering homebirth in an effort to ease the congestion in their wards. Am I dreaming? It sounds to me as though mothers and babies will do well out of the Budget.

Saturday, May 10, 2008

WAITING PATIENTLY
One of the big issues in having a caseload, and accepting nature's timing in birth unless there is a clear reason to interrupt the natural processes, is that I have no way of knowing when babies will come. The booking dates on my calendar do not tell me when or in what order the mothers and babies who are important to me as my 'caseload' will make their individual claims on my time and skill. I know I will have periods of waiting, as well as times when several babies are needing to be born. This is beyond my control, and my Christian faith allows me to trust not only that my Heavenly Father cares for me and wants to guide me in all the events in my life, but that each new baby is in God's care. There are times when I am tired, and I ask God specifically for strength, wisdom, and understanding as I do my work. In a post-Christian society this concept may be unpalatable to some, but it's very real to me.

This past week I have been busy, with a baby born at home on Tuesday, and twins born in the hospital on Thursday. Today I want to reflect on my emotional journey: waiting for each labour to establish, and being 'with woman' as she labours and births. I will call the mothers, in sequence, A and B - Anna and Beth. Although their due dates were more than a fortnight apart, it became clear that they would both be needing to give birth soon.

Anna's pregnancy had reached 41 weeks when she came into labour with her first child. The waters broke late Monday night, and her labour got started. I had a phone call in the wee hours, and went back to sleep after reassuring Anna, and encouraging her to rest if she could in this early stage of her labour. By the time I saw Anna in the late morning she was labouring well, on all fours, and feeling weary. I didn't want to in any way interrupt what was happening, so I sat in the other room with a cup of tea and my crochet. I encouraged her to be upright, and she progressed quickly. At one point she came into the room where I was, and she saw that I had my crochet, and the gear that I bring to a birth, set out and ready. Anna's baby was born beautifully in the birth pool a couple of hours later.

The principle of undisturbed birth, as I have learnt it from practice, and from readings, was confirmed again. Protecting and promoting normal birth, and working in harmony with the natural processes, requires the mother herself to accept and work in harmony with her labour, as much as it requires the midwife to be quietly protecting the space the mother is in.

Beth's twin pregnancy had progressed well and was now at about 39 weeks. Beth was receiving prenatal care from the Royal Women's Hospital as well as from me, and she had prepared her birth plan carefully and discussed it with the obstetric and midwifery consultants at the hospital. Beth's plan was that she wanted the opportunity to progress naturally and give birth to her babies without interference. This sounds very logical and reasonable, but is very different from the way most twins are born in that or any other hospital today. The decision to go to the hospital for the birth, rather than plan homebirth, was one that Beth had made, after considering the information she was able to gather about twin births. I had been her midwife for her first birth, at her home.

Earlier this week Beth came under increasing pressure from her obstetric carers to have an induction. The ultrasound had suggested that the second twin was smaller than the first, and *might* not be growing well. There is a widely held belief, which I think is a myth, that twin placentas will age more quickly than singleton placentas, and that it's not safe to let twin pregnancies progress to Term. This decision point - to intervene in the interest of one of the babies - became the challenge that Beth, and as her midwife and advisor, I faced. Beth found a recent article in an online journal which seems to challenge the ageing placenta theory. (See http://www.ispub.com/ostia/index.php?xmlFilePath=journals/ijpn/vol5n2/twin.xml)
I found this article useful in understanding the big picture, yet I was also wondering if the artificial rupture of the membranes for the first twin was really such a big deal. Beth also seemed to waver in her commitment to trusting and working in harmony with the natural process. We all knew these babies would be born soon. Perhaps we (Beth and I) should be more pragmatic and accept the induction? I assured Beth that the decision was hers, and that I would support her no matter what. I also encouraged her (and encouraged myself) to value spontaneous onset of labour, or at least natural onset of labour.

It can't be called truly spontaneous, as Beth proceeded with the less medical options - acupuncture, nipple stimulation, then a dose of castor oil. On Wednesday afternoon, after the castor oil, she felt regular contractions, but not labour. The booking at the hospital for induction was for Thursday morning. On Wednesday evening Beth called the hospital to say she did not intend to come in for induction, and took more castor oil. Labour became established; we went to the hospital after 6.30am, and the babies were birthed, seven minutes apart, an hour later. It was a 'normal' twin birth - there were none of the complications that we know are possible; no drugs were used; and Beth declined continuous monitoring, and an IV cannula. The second baby was smaller than the first, which is not unusual, but the placentas were healthy - no sign of ageing.

I have mentioned only fragments of the whole story. The record I want to put down today concerns my feelings as I waited for and attended these birthings. It's as though I have a parallel existence to the birthing woman - I need to 'nest' in those final days so that I am prepared for whatever happens, and I face transitions when doubts and fears arise and sometimes swamp me. I can't have a blinkered belief that 'natural is good', because I know that in nature there are many undesirable outcomes. I have to use my knowledge of the human body and birth to protect wellness, as well as to access the best medical services if they are needed. There is no clear 'black and white' in this decision making. The guiding principle is that in birth and nurture of the infant, there is no safer way than to work in harmony with the body's own natural processes, unless there is a clear reason to believe that the natural processes are not likely to lead to the best outcomes.

In both of these birthings, these women could have easily relinquished their authority and rights as the birth 'giver'. Anna's labour could have been induced for convenience, or for 'postmaturity'. Beth's labour could have been induced for this vague idea of 'ageing placenta' or 'non-reassuring ultrasound'. Once the woman submits to the authority of someone else, a doctor or a midwife, who reaches into her vagina to artificially rupture the protective membranes around her baby, it is very difficult for that woman to take back her authority for her own birthing. The hospital's expectations for progress and monitoring become the benchmark for decision making from that moment onward. The pain that the woman feels after induction is interpreted by her as different from what she feels if her body is taking her there naturally.

Again I have been honored to witness the power of women in their birthing. I hope many other midwives are able to work in this ancient and timeless model of care, and protect the authentic role of the midwife, being 'with woman'.

Thursday, May 01, 2008

A Normal Birth
I attended a birth early thismorning, and as I had no apprentice midwife with me, I am going to try to set down an account of the amazing yet totally ordinary sequence of events from a midwife's point of view. Some of the readers of this blog are midwives and midwifery students who are wanting to learn the specific skills of a midwife working with women in community settings, with the intention of promotion health and wellness, and working in harmony with the natural processes. I hope there is something in this account for you.

0200 - phone call from "Matt", "Jenny"'s partner - labour has started. Jenny came to the phone, "Yeah, they're about 10 minutes but they're str --- just a moment --- (quiet focused breathing) --- strong."
"I'm on my way. See you soon," I said.
I drove through the quiet streets, and covered the 35 or so Kilometers quickly.
I had seen Jenny a couple of days ago. She was unsure of her dates, and an ultrasound at 25 weeks had set the due date at 2 weeks ago. That day came and went, and Jenny and I felt confident that there was no cause for concern. The baby would come.
0300 - I arrived at the home, in a beautiful bushland setting on the outer metropolitan fringe. Jenny was working quietly in her dark bedroom, and the birth pool in the corner was being filled. Jenny's mother had a wood fire going and made me a cup of tea. In one corner of the main room I opened up my gear, connected the oxygen cylinder flow meter, and took out the paperwork. The basics needed for any birth are quickly put out - the pack of instruments (sterile scissors and metal cord clamps) in a big green plastic kidney dish; a pair of sterile gloves for an internal exam if needed; procedure gloves for catching the baby, and handling blood; a plastic cord clamp; the oxytocics, syringe and needle.
Then I sat quietly with Jenny, observing her and getting a feel for her labour. During this time I use both my thinking brain and my intuitive brain. Just as mothers use their intuitive brain in undisturbed birthing, a midwife learns to partner that woman in a very real sense, going through the stages, emotionally and in a deeply connected way, with her.
Very little conversation happens - I ask "is baby telling you anything --- are you getting any kicks?"
"Oh yes, with the contractions."
The mother probably doesn't realise how significant those kicks, which she alone knows about, are. Her simple statement is reassuring to me. Healthy babies cope well with labour, and a baby that gives mother a kick during contractions is doing well.
"Are you happy for me to listen to your baby after the next contraction?" I ask. The heart sounds tell me what I already know.
Jenny got in the bath and said "Aaah, that's good". Her labour progressed quickly. By 0345 she was vocalising and saying "No, I can't do it" during the contraction, then saying to me "That's transition" after the contraction. The transformation of a woman at this time of peak adrenaline together with peak oxytocin and endorphins is marvellous. Then, as she was kneeling in the water "She's here!", followed by "help me." My hand was near her hand as the little head, then shoulders emerged into the warm water, and I lifted the baby gently to the surface.
It was 0400. Noone had seen the 'birth' - that's one of the special features of waterbirth. I shone my little torch briefly and confirmed that baby's colour was good. We waited for the best part of a minute while the newborn adjustments took place wonderfully, followed by a little cry and other movements. There was no hurry. This child was unstressed, peaceful, and well.

Jenny settled back into the water and rested, looking alternately at her beautiful daughter, and to her lover. I don't remember if anything was said. I was happy to just be there, in the background, keeping the space.
We had a comfortable arm chair set up next to the tub, draped with an old shower curtain, towels, and an absorbant pad. My notes tell me that Jenny got out of the birth pool at 0415. We supported her and dried her off as we assisted her to get out, while she held her baby to her breast. After a couple of strong contractions Jenny felt the placenta coming, and she moved forward in the chair. I received the placenta, with minimal blood, in the green plastic kidney dish. Together we checked the placenta, and Jenny and Matt felt the surfaces as I explained it. Jenny had decided not to cut the cord, so we wrapped the placenta in an absorbent 'bluey', and placed it near the baby.

In the next couple of hours Jenny fed her baby; I got the paperwork done; the two big brothers met their baby sister; we all had tea and toast with vegemite, honey, or peanut butter; photos were taken; more logs were put on the fire; and as Jenny snuggled up in her bed with her sleeping baby she asked me to close the door. I left the home confident that everyone was strong and well.