mothering

The mother of a two-and-a-bit year old commented wistfully, "I had no idea of what I was committing to when I became a mummy."


That's so true.

In fact, I don't think it's possible, prior to the experience, to understand something as absolute as the basic, intuitive, hormonally mediated changes that occur in a woman's life when she takes her child into her arms and puts that child to her breast.

Thanks to Miriam and Amelie

This mother who, for whatever reasons, started her family in her mid- to late-thirties has probably experienced a great deal of freedom and responsibility in her personal and professional life.  She has experienced leaving home, and becoming independent of parental influences.  She has possibly experienced promotions and increases in her work earnings.  She may have enjoyed overseas travel or achieved success in the personal pursuits that she has chosen.

...

And now, at about 40 years of age, she has her two-year old constantly in her care, and is preparing for the arrival of a sister or brother.


The day begins with "I very hungry now mummy", and continues as she seeks to meet each of the needs of the child. Multiple meals and snacks, nappy changes, library, play group, walks to the playground, playing hide-and-seek, art work at the kitchen table, music, visits to friends, daytime sleeps, melt downs because the little one didn't get all the sleep she needed, sweeping up crumbs and food scraps under the table for the n-th time, and thinking about upping her dinner menu to something special tonight.  These are just a few of the day's challenges, along with shopping for groceries, mountains of washing, drying, folding and putting away the clothes, getting to appointments on time, and much more.

There is no suggestion of complaint in this mother's musings.  Most of the time she patiently accepts the work of caring for one small person; valuing her own role as mother above all other options at this time of her life.  University education and professional standing cannot compete with the status that is simply and profoundly accessed under the title 'mother'. 


Am I being idealistic?   Am I seeing only what I choose, through the filter of many years; forgetting the reality of sleep-deprivation, and the constant and unrelenting need of the little one for attention? 


I don't think so.  I see a great mystery, something timeless and inexplicable, in the ability of a mother to care for her children.  I accept that many aspects of mothering call for a commitment that goes far beyond our usual limits, and that it's not possible, prior to the experience, to understand something as absolute as the basic, intuitive, hormonally mediated changes that occur in a woman's life when she takes her child into her arms and puts that child to her breast.

The mystery of the mother is our birth-right; contained within the wonderous bodies that God created in his own image, and that God said "is good".  Mothering is part of the natural physiological process that can happen automatically in a woman's person during pregnancy and after the birth of her baby.  It's the same normal physiological process that I as a midwife have sought to protect, promote and support, unless there is a valid reason to take another, more medical, pathway.

Yet the ability of a mother to give, and give again, is not to be taken lightly.  The presence or absence of loving support and encouragement from husband, family, friends and within the community can make a huge difference.


I recognise that mothers today are expected to return to paid employment after their babies have reached one year, or even six months, with children being placed in day care.  I cannot accept this as being in the child's or the family's interests.  In the end Australian families will be paying a high price for this social experiment that interferes with the basic building blocks of love and attachment between mothers and their babies. 

Mothers who are willing and able to nurture their own babies should be supported to do so. 

Obstetric violence in Australia today?

This is the definition of obstetric violence, presented by UK obstetrician Dr Amali Lokugamage at RCOG World Congress 2014 in India:

"Obstetric violence is the act of disregarding the authority and autonomy that women have over their own sexuality, their bodies, their babies and in their birth experiences.
"It is also the act of disregarding the spontaneity, the positions, the rhythm and the times the labour requires in order to progress normally when there is no need for intervention.
"It is also the act of disregarding the emotional needs of mother and baby throughout the whole [childbearing] process" 
Jesusa Ricoy-Olariaga 2014

Today I want to carefully reflect on a couple of births and other maternity experiences that are very close to home.  
I want to carefully measure the maternity culture that I know and participate in, in and around Melbourne today.  
I want to ask in what way I am contributing to obstetric violence.
I want to seek ways by which adverse aspects of a culture can be changed.

[Please note that names and some of the details in the cases have been changed for anonymity]

Case study 1
Bess was a 30 year-old, carrying her third child, planning homebirth.  I have been her midwife for each of her births, and her first and second baby were born at home in my care.

At about 36 weeks, Bess visited her GP, who looked at her abdomen, and said her baby was too small - growth restricted (IUGR).  The GP quickly arranged an ultrasound scan, which appeared to support the diagnosis, and an appointment for Bess at the tertiary hospital.  The GP spoke to me about her concerns, and I wondered if I had missed something.  

.... fast forward to 38 weeks
Bess was advised to go to hospital to have an induction of labour.  She asked me if I thought her baby was too small.  I did not.  However, I told her "If I'm wrong, and there is a valid reason to get this baby born (as she had been advised by the hospital and the GP), you have more to lose than if I'm right."

... fast forward to a couple of days after the birth of her baby (whose weight was well within the normal range).
Bess told me she did not feel traumatised by the experience: rather, she had faced the challenge head on, and accepted the intervention of induction of labour by artificial rupture of the membranes (ARM).  She had progressed unmedicated, and gave birth without assistance to a healthy baby boy.   When she was told, a couple of hours after the ARM, that it was time to commence IV Syntocinon, she declined and was quite definite about not needing further intervention.  She knew from the tone of the contractions she had experienced that her baby was on his way. 

Obstetric violence monitor (using the above definition):
-1  Bess was pressured by (albeit well-meaning) doctors and maternity care system that introduced fear of harm to her baby, when in fact her pregnancy was progressing normally
-1  Spontaneous onset of labour was denied
+1 Bess was able to decline further intervention after the ARM
+1 Bess considered that, despite experiencing pressure to comply with medical plan, her decisions had been respected, and she felt emotionally supported

Score: Pass - Case 1 is not an example of obstetric violence

Comment:  There are many contributing factors in any decision-making.  The choices that a woman has around her maternity care, and the decisions she makes at any time, are not equally weighted.  The support she has, both professional (eg from a known and trusted midwife) and personal (eg from partner, family, friends) will probably influence outcomes, especially if the decision-making pathway is not clear.

Case Study 2.
Deb was a 38-year old mother who had had two caesarean births, both prior to labour.  Deb wanted a VBA2C (vaginal birth after 2 caesareans) for this birth.  She considered herself well informed about making this plan, and made sure that her written birth plan was included in her hospital record.  She had felt cheated in her previous caesareans, and longed for the spontaneity and bonding between mother and baby in normal birth.

Prior to the onset of labour, Deb had some bright bleeding from her vagina.  She went to the hospital, and had some electronic fetal monitoring and other investigations.  The doctor told Deb that her baby did not seem to be distressed, but that he strongly recommended a repeat caesarean immediately.  Deb explained to him that she would accept a caesarean birth, even though it was not what she had so much hoped and planned for, if the hospital would permit her to keep her baby with her, skin to skin, in the operating theatre, in the recovery room, and when they had returned to the postnatal bed.  The doctor went away to make this arrangement, but was told the hospital did not provide staff for that option: that the baby and his/her father would be taken to the postnatal ward, and the mother reunited with them as soon as she was released from the recovery room.

Deb then refused the emergency caesarean.  Deb's baby was, a couple of days later, still born.

Obstetric violence monitor (using the above definition):
-1  The emotional needs of the mother were disregarded
-1  The emotional needs of the baby, as understood by the mother, were disregarded

Score: FAIL - Case 2 IS an example of obstetric violence

Comment:  Deb's case is clearly complex from an obstetric/medical point of view, and I have cherry picked a few facts in coming to my conclusion that this is an example of obstetric violence.  The hospital disregarded the clearly expressed emotional need of this mother, and used inflexible staffing arrangements as the reason for denying her request.



In what ways am I contributing to obstetric violence?
There is no simple tick-box for obstetric violence in maternity care today.  As evidence emerges about the finely orchestrated hormonal processes in birth and nurture of the new born child, the expectations of women will change.  The providers of professional maternity services must also integrate the contemporary knowledge into our care.




One of my own babies was born with a fractured clavicle, and aspirated mucus, as a result of rather rough handling by the doctor.  The mucus was cleared from her lungs using suction and percussion, and the clavicle healed as expected.  But that child became fearful and anxious when ever her throat became inflamed.  She had a definite memory of pain that had been caused by the failure of my accoucheur to permit me to give birth to her spontaneously.  She had experienced obstetric violence.  I did not feel or know that I had been traumatised - the requirement for me to be lying on my back with my feet in stirrups was standard at that time.

At about that same time, in the 1970s, there were dark and horrible secrets in many facilities where children received care.  Predatory sexual activity, and physical and emotional abuse, were tolerated within the system.  A blind eye was turned.  It has taken several decades for the light of public scrutiny to be directed towards those institutions, and for the people who experienced such abuse as children to have an opportunity to tell what they can of their stories.  

In reviewing birth as I know it in Melbourne today, I want to ensure that I and my colleagues are not tolerating - turning the blind eye - situations of abuse and violence against women and babies.


The maternity system as we know it today does not protect, promote and support natural physiological processes in birth and nurture of babies.  It does not follow the standard, that "In normal birth there should be a valid reason to interfere with the natural process." (WHO 1996)

It is possible that future generations will look, aghast, at the way mothers and babies are being treated in the early 21st century, in the same way that we are shocked by revelations of institutional abuse of children in the C20. 

midwifery: protecting health across generations

Maria Lactans (17th Century) Antwerp

One of the truly compelling reasons that I have for practising midwifery the way I do is the knowledge that there is no safer, no better way for a baby to be born and nurtured than the way our bodies have been wonderfully created to do it.  The marvels of science and medicine have not come up with a better process.  

I'll call it NORMAL birth: normal from a biological, physiological perspective in ideal conditions.
Not what *normally* happens today.
Not what is most common in birth today, or 100 years ago, or in a primitive society .... 

NORMAL birth requires a strong healthy woman who carries her pregnancy to term, and comes into spontaneous labour.  It requires the mother to accept and work with her body in labour, and to progress, without medication, to the climax of birth.  It requires the mother and baby to work together in establishing breastfeeding, within a nurturing family-community setting that supports the mother in these challenges.

This 'ideal' is what a midwife seeks to facilitate. "In NORMAL birth there should be a valid reason to interfere with the natural process." (WHO 1996)

At any point in the process we can face challenges, complication, illness, and the need to intervene.  That's when science, medicine, obstetrics ... become life-saving.


There are obvious and unquestioned benefits to a mother and her baby when the NORMAL processes are protected, promoted and supported.

• A mother's body and mind respond in unison to the changes in hormones in her blood, as she prepares, and progresses.  
• The mother's thinking brain is suppressed, in a quiet and unstimulating environment where she does not feel that she is being observed, so that her instinctive mind is free to proceed with the final nesting, and the surrender that accompanies strong labour.  
• The baby is born alert and healthy, ready to engage in the instinctive breast crawl as breastfeeding is initiated.   
• Early and effective suckling at the breast, together with the physical pressure of the baby's weight against the mother's uterine fundus, lead to strong contractions and completion of the third stage.  
• Once the placenta and membranes are completely expelled the risk of haemorrhage is minimised, and continuing breastfeeding supports the involution of the uterus.  
• Close physical contact from the time of birth supports the development of normal bacterial flora on the baby's skin and digestive organs, preparing the baby's immunological processes for ongoing function.  
• Bonding between a mother and her newborn proceed as they make eye contact, with uninterrupted close contact, and the mother's body is awash with love hormones.

I have not mentioned the midwife.  Yes, the midwife is present, working in harmony with the NORMAL processes, and guiding and supporting when things get difficult, but staying quietly and unobtrusively out of the limelight.  The midwife is guardian - protecting the mother and her child, and providing a safe space for them in NORMAL birth.

When there is a valid reason to interfere with the natural process, the midwife guides the woman, and provides appropriate explanations.  The midwife seeks only the health and wellbeing of mother and child.


Today I am looking further than the primary episode of care, spanning the nine months of the pregnancy, and the six weeks of the postnatal period.

I am looking at future generations.


The study of epigenetics: "the study of heritable changes in gene activity that are not caused by changes in the DNA sequence" offers huge challenges in health care, and particularly at the beginning of it all; conception, pregnancy and birth.  Emerging within this field of science is a new respect, for example, for the effect of nutrition during a woman's pregnancy on the health of her grand-children - the children of the child forming in her womb.

I have no claim to expert knowledge in biology, but would encourage readers to keep exploring this field.

Our bodies are wonderfully made.

I have recently become aware of a new film project,
micro birth

"MICROBIRTH" is a feature-length documentary looking at birth in a whole new way, through the lens of a microscope.
The film explores the latest scientific research into the microscopic events that occur during and immediately after birth.
This compelling, brand new science is starting to indicate that if the natural processes of childbirth are interfered with or bypassed completely, this could have devastating consequences for the long-term health of our children.
Just to be clear, this film is not calling for an end to interventions as many times they are essential and they can be life-saving.
But as this new science is starting to indicate, the use of synthetic oxytocin to induce or speed up labour (Pitocin / Syntocinon), antibiotics, C-section, the routine separation of mother and baby immediately after birth and formula feeding, could significantly raise the risk of our children developing serious disease later in life.
And as the film shows, the medicalisation of childbirth could even be contributing to a potential global human catastrophe predicted to happen by the year 2030.

...