Sunday, November 23, 2008

Is childbirth education possible?

I used to call myself a childbirth educator. I used to teach classes for expectant parents whose minds were as thirsty for the words and concepts of childbirth as the desert sand is for rain. I used to use the doll and pelvis, and speak with authority on optimal fetal positioning. I knew that to stand in front of a room full of eager, intelligent women and their men was a rewarding, satisfying event. I had what they wanted - the knowledge of childbirth.

As time has passed I have become progressively less interested in trying to explain the secrets of birth in a didactic, classroom setting. In fact, I ask myself the question in the title of this blog, "Is childbirth education possible?" A short course in obstetrics, or even midwifery, does not educate anyone to be able to give birth.

Of course you can be educated about what happens as labour gets established; about the colour of the amniotic fluid and normal progress in labour. "We" (those in the know) can educate "them" (those anticipating childbirth), using language passed down over hundreds of years of our civilisation - many of the words being Latin. Those being educated quickly learn that the labia are the lips; the cervix is the neck; the liquor is fluid; rubra means red, and alba means white.

Some forms of childbirth education have moved away from the medical language and call the uterus the womb; contractions are surges; the ilium is the hip bone and the ischium is the sit bone.

When teaching childbirth classes in a hospital I had access to wonderfully coloured charts and educational aids. A class in the series was about the options for pain relief in labour. There was a plastic model of the spine, with each vertabral bone sticking out from the plane, and an illustration of where the long needle was placed so that an epidural or spinal anaesthetic could be injected. Another class included a tour of the labour ward. Fathers-to-be were particularly impressed with the machinery of birth: the machine that goes 'ping', the electronic fetal monitor, being able to attract a crowd of curious onlookers. Classes like this are going on in maternity hospitals every week. Education about obstetrics; orientation to the maternity facility; preparing people for what will be done when the time comes for their babies to be born: yes. But education for childbirth? Not really.

I have listened to education that focuses on emotions experienced in labour. Dads-to-be are exhorted to support and encourage their partner in practical ways. Mums-to-be are prepared for their crisis of confidence. Supporters are told that the (support) chain is only as strong as the weakest link. You must hold faith. You must believe.

When I was pregnant with my first child in 1973, I was impressed with the Lamaze childbirth education, and attended a series of classes. The French doctor Lamaze, who taught breathing techniques and psychoprophylaxis and talked about Pavlov's dogs and conditioned reflexes, had eclipsed his English colleague, Dr Grantly Dick-Read, who taught that pain in childbirth could be minimised when the labouring woman understood what was happening, and thereby approached birth without fear. Dick-Read is considered by many to be the father of the childbirth education movement. Today I encourage mothers to learn in a maieutic way, intuitively.

Today many classes are available, and I cannot make comments on individual styles of education for childbirth. My observation is that education is about head knowledge. It's about understanding the processes, rather than enabling the fulfilment. As I said, a short course in obstetrics, or even midwifery, does not educate anyone to be able to give birth.

Giving birth is not an act of a conscious mind. It is not something that we can plan or organise or control. Giving birth is the climax of an amazing process in which physical, emotional, and hormonal systems are orchestrated within the bodies of the mother and child. Giving birth requires the mother and all who are close to her to firstly learn to work in harmony with her body, then when the time comes to yield to her birthing power. That learning is done on the job. The mother must willingly engage with her labour, without any distraction, and learn intuitively what will assist and what will hinder her progress. She must choose to be strong; not expecting to share her job with anyone. Her support team or even her midwife cannot do this for her. It is internal learning, and knowing.

A young mother had been labouring through the day, and her labour became strong as the night progressed. From palpation I knew that her baby was a good size. I estimated that she should be coming up to full dilatation by about 1am, and I prepared myself for a birth at home. Baby's heart beat was consistently good.

By 3am I was wondering where the baby was. I checked internally and found that the cervix was probably fully dilated, but the head was high - well above the ischial spines. It had barely entered the birth canal.

By about 7am, after doing all we could to encourage progress, we agreed to transfer to hospital and get some help. However, the traffic in Melbourne at that time of day is heavy, so I suggested we wait a while.

By 8am a major change had occurred. The young mother had found the way! With new strength that she could not have known existed, she brought her baby through her birth canal, and on view. Each effort was amazingly effective.

How did she do it? Childbirth education classes had not taught what she needed to know that morning. She learnt from within herself, using the God-given intuitive knowledge that mothers have to enable normal childbirth. It wasn't the encouraging words of "You can do this", or any instruction from me or anyone else. A woman gave birth to her first child.

Our hearts were overflowing with thankfulness to the giver of life as we welcomed that beautiful child.

Tuesday, November 18, 2008

MATERNITY SERVICES IN VICTORIA, AND THE FEDERAL GOVERNMENT’S MATERNITY SERVICES REVIEW




The Review by federal Health Minister Nicola Roxon has attracted an unprecedented number of responses. Maternity services are important to our society!

Victorian government’s policy Future Directions for Victoria’s Maternity Services (2004) is the framework that will guide developments over the ensuing 5-10 years. The policy seeks to “work towards quality birthing services where providers have a multidisciplinary approach and where women are informed and have choices.”

The current mix of federal and state funding for maternity care restricts a woman’s access to care by a known midwife of her choice, and protects a monopoly of doctors as the only providers of maternity care. Birth is not an illness, yet public funding for maternity care, as well as private health insurance, fragment the care into medical items within schedules.

What is the state of maternity services in Victoria today?

1. Choice of midwife led primary care is available to some women – see Attachment 1 ‘Having a baby in Victoria’ below.

2. Detailed information on hospitals and number of births is available from Vic Perinatal Data Collection Unit (PDCU) perinatal.data@dhs.vic.gov.au

Attached copies from the PDCU 2007 report Hospital Profile of Maternal and Perinatal Data (attached to this blog as photographs - not particularly good quality, but I can't see how to link a scanned page to this blog!)

• P20 Onset of labour for women who gave birth 2006, with comparison of data for public hospital, private hospital, and homebirth
• P21 Epidural/spinal analgesia in labour primiparae and multiparae- comparison of data for public hospital, private hospital, and homebirth
• P22 Intrapartum analgesia
• P22 Type of birth
• P23 spontaneous vaginal births, forceps births, vacuum births - comparison of data for public hospital, private hospital, and homebirth
• P42-43 graphs of public and private data for maternal age group, maternal postnatal length of stay, type of labour, and type of birth

3. Care options are dictated by private health insurance – approx 36% of women in Victoria give birth in private hospitals
• Bookings at private hospitals are made through specialist obstetricians – (very few general practitioners)
• Outcomes for private hospital intervention rates are consistently higher than public hospitals, even though women with complex medical needs are often referred to public hospitals
• Midwives, who by definition have a duty of care to promote normal birth, are not able to be primary care providers for any women in private obstetric care. The midwives in these hospitals are subservient to the obstetricians in all care decisions.
Maternity Service Performance Indicators are published giving detailed data for public hospitals, and only aggregate data for private hospitals.

Attachment 1.
Source: Janie Nottingham - used with permission
‘Having a baby in Victoria’
In 2006, 68 547 women utilised birthing services in Victoria, in 2007 this has grown to 72 000.

64.1% of Victorian women utilised public maternity services

200 women gave birth at home by choice

The Victorian State Government issued a paper on maternity services reform, Future Directions. This document supports the establishment of primary midwifery models of care, with particular emphasis on ‘caseload models’. Caseload midwifery is where one midwife cares for one woman. The benefits and cost savings of caseload or 1-2-1 midwifery are well documented. The World Health Organisation considers this care the most appropriate for the 75-80% of women that experience normal, healthy pregnancies.

Despite the cost savings and benefits there are few public funded ‘caseload models’

Sunshine Hospital has recently established a caseload service for 1000 women

Geelong offers a service for 470 women per year. They are turning away up to 25 women per month who want to access the service.

Royal Women’s is currently conducting a trial caseload service for 1000 women. It is well known that trials in innovative maternity care (despite positive outcomes) rarely transform into established services.

Box Hill has a Know Your Midwife service. Ironically this service does not include care in labour (the most critical time to have a known carer)

Since 1997 37 rural based obstetric units have closed, with Daylesford planned to close later this year. Only one has re-opened (Seymour). Women and their families are forced to travel for basic healthcare. The financial and emotional costs to families are considerable. There is a wealth of evidence outlining the safety and improved health outcomes of local maternity care (particularly primary midwifery care)

Rosebud Hospital closed its maternity service in 2007. Officially this was due to a loss of Obstetric cover. This decision contradicts current evidence, Victorian policy (via Future Directions) that demonstrates the safety and success of primary midwifery units.
The Angliss suspended its caseload midwifery service despite stunning outcomes in 2004. Ironically just before the release of future directions
The midwifery workforce, Australia-wide is not used to its capacity. Midwives are educated and registered to provide the entire care to healthy women.

Data sourced from the perinatal data collection unit stats

Wednesday, November 12, 2008

Maternity organisations - members

A maternity organisation may have begun with a small number of members who all worked together towards an agreed end. These people met and talked and each one learned how they could contribute to the work. They saw the need to formalise their structure, so they obtained a model constitution, adapted it to their needs, and became incorporated. Money was needed, so a membership fee established. A treasurer was chosen, and bank account set up. The rules required certain other office bearers, and before long it was time for annual reports and financial audits and an annual general meeting.

The decision making process in a maternity organisation has usually been, in my experience, based on consensus. While everyone is working together, this style has worked well. Members of the organisation's executive are likely to reach agreement quickly, with minimal debate, on proposed actions. The person who proposes a course of action is often the one who takes leadership of that project on behalf of the organisation. There does not seem to be a need for a parliamentary style of motions being seconded, discussion, amendments, more discussion, and voting.

Is consensus decision-making any less robust or reliable than the parliamentary style? I asked this question years ago when I was a beginner in voluntary associations. I was told that the consensus style is more feminist, while parliamentary style is more male. Female processing makes a lot of sense for anything maternity! For the time being I accepted that explanation.

Today I would say that although I still support the consensus style, this should not be confused with complacency. I see every member of a committee as having responsibility for the actions of people on behalf of that committee or board or group. It is important that proposed actions be agreed upon, and the notes of the meeting record the fact. It's also important that someone follow through and report progress until the action is completed. It's all too easy to sit back and expect someone else to do the work. It's also dangerous if the group becomes a rubber stamp committee, when one person dominates the meeting, and everyone else agrees without using their own minds to question or engage in critical review. As the complexity and cost of projects increases, so does the expectation of transparency and accountability.

As more members are signed up into the maternity organisation, and more money is brought into the organisation's bank account, there is an increasing amount of work for someone acting on behalf of the committee to process and manage memberships. As a volunteer organisation, the committee depends on volunteers whose skill or commitment may be more or less competent or available at particular times, for all sorts of reasons. A reliable process of managing membership subscriptions, so that membership lists are kept up to date, and financial accounting can be correct, becomes essential. It becomes increasingly expensive if paid professional services are engaged to do the work. Yet a point will be reached where the volume of work and the skill required exceeds that which can be reasonably expected of a volunteer.

Maternity organisations will always need volunteers who are elected by members to manage the work of the organisation. As the organisation grows, prudent planning by its office bearers can ensure succession planning for the various positions. An organisation that has annual elections for all office bearers is put at risk of losing corporate knowledge if there is a large turnover. The rules can be changed to protect the organisation from this, by having, for instance, three-year terms of office, and a requirement for only one-third of the office bearers' positions to be voted on each year. However the advantage of having one-year terms is that office bearers who are not performing well can potentially be voted out sooner rather than later.

Tuesday, November 11, 2008

Leadership styles

The style adopted by the leaders within an organisation can either support or inhibit the work. Organisations with a maternity focus draw most of their committee and members from the people most interested in maternity issues: mothers and midwives. Some volunteers come into both categories. Occasionally a person whose 'tag' is father, or granny, or something else, will put up their hand to work to achieve the purposes of the association.

The hormonally-driven behaviours common to mothering across many animal species encourage a mother to protect her own young. The bonding between a mother and her infant, resulting in focused attention of that mother to that baby without limit, is a natural phenomenon that no modern technology or systems can replace. Midwives encourage new mothers to listen to the intuitive promptings within their relationsips with their babies.

Mothers of babies and young children are unlikely to be able to devote vast periods of time to voluntary work. Most volunteer mothers and midwives have complex sets of commitments to their families, their paid jobs, and their personal interests. Most volunteer mothers find time when their children are asleep to go to their computers, read messages, write replies, make phone calls, and do the work they have committed themselves to.

A leader who encourages others to engage in the work they have committed to, and to give their best to the work is at the same time supporting the newer volunteers to improve their capacity in that work. A leader who undermines the work of a volunteer, or who takes a strongly authoritarian position (sometimes called micro management), will find a diminishing supply of voluntary workers.

A leader who recognises potential in a person who is showing some interest in the work, and who mentors and guides by example, will find others who take up the challenge of the work, and who develop new skills and new confidence over time.

I have found that there is usually far more work that could be possibly done within a voluntary association, than capacity within the people who are active at any time. We always face limitations, both personal and financial. Each group needs to prioritise, and the activities planned will usually be those that match the interests and abilities of the committee at the time. A leader or president who lacks trust in others' ability to act on behalf of the organisation is in fact limiting the work of the organisation to what she or he can perform. That leader can only continue if the committee is willing to 'rubber stamp' any plan suggested by their president. A leader who facilitates and enables others to take responsibile action multiplies the potential output of the group.

There is no place for carelessness in a voluntary association. There is no place for "I'm just a volunteer". An action that is agreed upon should be carried out to the best of the ability of the person who agrees to do it. All who take on roles in the organisation are expected to be accountable, and to act in the interests of the group.

In considering leadership style I recognise that I am seeing the issues from a midwife's perspective, not that of a business person. A midwife develops a relationship with each woman, and learns to work in harmony with the woman's own strengths and weaknesses to promote natural physiological processes. A business executive, on the other hand, has definite expectations of performance and outcomes.

An organisation that seeks to improve the maternity experience in some way for mothers and babies, or for families, does well to model itself on the mother-midwife partnership in promoting normal birth. I would encourage all who commit to such work to truly value each other, in whatever capacity you and other committee members are able to work. There are practical ways that each person can contribute to achieving an organisation's purposes and goals.

Thoughts about maternity organisations

Today I am beginning a new theme, maternity organisations, which I plan to write about over the coming weeks. I hope that these thoughts will be productive, in supporting those who generously volunteer their time, skill, and energy to improving maternity care for all women in a society. I am writing about issues, not individual people. If any reader wishes to suggest an issue or topic, for my comment, or to make a guest comment on this blog, please contact me.

Voluntary associations require a set of rules and a committee to manage the affairs. The rules are the constitution, and if an organisation has become incorporated in law, the rules and an annual statement are lodged with a statutory body, such as (in Victoria) the Office of Fair Trading and Business Affairs at the Department of Justice.

Anyone who is interested in understanding how organisations work can check websites such as Our Community, or read well respected text books such as N E Renton, Guide for Meetings and Organisations, volumes 1 and 2.


THE TATE FAMILY

The TATE family are members of our Club.
First of all, there is DICK TATE, who wants to run every activity.
Then there are his two brothers - RO TATE, who tries to change everything, and POTEN TATE, who wants to be the big shot.
Their sister, AGI TATE, likes to stir up trouble and her cousin IRA TATE, often helps her. Another cousin, IMI TATE, wants the Club to mimic everybody else.
The parents, HESI TATE and VEGE TATE, pour cold water on all proposals put forward by the committee.
The annual meeting always groans when another relative, DEVAS TATE, stands up to speak. But FACILI TATE often moves constructive amendments.
The most delightful member of this large family is FELICI TATE, while old ES TATE is always welcome for is generous donations to Club funds.
(Source: Renton, 6th edition (1994), Volume 1, page 306)

Monday, November 03, 2008

Normal Birth: the baby

What is normal for a baby?
What conditions are optimal for a newborn child as the transition from life in the womb to life out here takes place?
What does a baby expect, in a normal physiological sense, in those moments after birth?

Recently I watched a wildlife documentary from Africa, following the annual migration of wildebeest. As the birth of a wildebeest calf was documented, the point was made that the cow and calf needed to forge immediate bonds essential for survival of the young. Senses of smell, taste, and hearing become central in the attachment between mother and child.

I believe the human mother/infant bonding process is no less dependent upon these normal, physiological factors. I believe our 'advanced', medicalised birthing rituals have become so accepted that we as a society have all but forgotten the importance of natural, normal forces that are keys to normal birthing. Our babies deserve the best start that we can provide for them. That best start is, without a doubt, being born strong and energetic, free of mind-altering drugs, and being taken by the mother to her breast with no unwarranted interference from other people.

During pregnancy a baby gets to know one person - her or his mother. The way that woman moves and breathes and talks and reacts: this is all home ground for that developing fetus. After birth the baby is absolutely at home in the arms of the woman who has carried him or her through the past nine months. Her voice is familiar; her laugh brings a memory of the laugh inside that warm safe place, when the little one learnt that with the laugh, or the embrace of the loved one, comes a surge of good hormones.

Not only does the baby recognise her mother's movements and sounds; she is also prepared for the microbiological world of her own mother. Her blood stream is already primed with antibodies to any organisms that the mother's immune system has encountered. As the newborn child is held naked against her mother's naked breast; as the mother whispers words of welcome and kisses the little nose, the baby's skin, digestive and respiratory systems are quickly populated with the normal bacterial flora from the mother and her home.


As a mother enters the most demanding stage of normal labour, as she experiences that altered state of consciousness, she may feel extremely weary. A thought flashes through her mind "how much longer can I keep going?"

Then, with the birth of the baby, the tiredness leaves her. A surge of adrenaline and other stress hormones passes through her, and her baby, supporting the birthing effort. The baby's body is physiologically primed to respond, and make the amazing adjustments that are essential in normal birth. There are several simultaneous events: the cooling of the air on his face; the change from a warm, dark, uniformly fluid filled environment to the air, light, and sound of our world. As the baby's chest moves out of the birth canal, his arms passively move away from his body, free from the previous constraints. That physical action draws air into the lungs, and together with the other complex changes initiates normal breathing. Changes in blood flow from the heart to the lungs happens simultaneously, quickly reducing the blood flow to the placenta, as the newly opened lungs take over the job of providing essential oxygen. Baby's eyes are open; pupils dilated; all senses fully primed. Smell, sight, hearing, touch, taste - and the baby's mind is recording and processing every sensation.

This is a mere thumbnail sketch of the amazing transition that happens every time a baby is born in harmony with the natural birthing processes.

Saturday, November 01, 2008

normal birth

In this video I summarise the 'bare necessities' of normal birth.
If you would like a .pdf file to print out a page on this discussion, please contact me via the comments section, or by email joy@aitex.com.au
The video is very brief - it takes about a minute.

video