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. 

Welcoming the newest member of the family

Thanks to Bec and Al for this picture

In the past few weeks, in writing this blog, I have delved into personal memories and thoughts, preparing for and anticipating a particular birth.   I expect this fact has been clear to many of my readers; many being women with whom I have shared that deep and wonderous journey.  Although I usually write in an impersonal way of 'the woman' and 'the midwife', so much of my knowledge of midwifery is inextricably linked to my own experiences in childbearing and mothering - intensely personal.  In many ways, I am the woman; I am the midwife; I am even the child.

Tonight as I sit at my computer, thinking of how I can express the wonder that is welling up in my heart, I hear the brief small cry of the wee one in another room of our home.  I know she will soon be transported back into that milky dream world, her little body being nourished by the abundant supply that is freely given.

I treasure the memory of the first view of her beautiful face, and the ecstatic glow on her mother's face, as we three - mother, child, and midwife - three generations of a family - shared in the moment of birth.  I look at her, and wonder what her life will bring.  I practice using her name.  This is a new name; a new person who I will treasure and pray for, for the rest of my days.  I look at her features; the colour of her hair, the exquisite tone of her skin, the wonderfully made body.  I observe the deep bond that is apparent in her mother, her father, and her 'big' brother; instinctive and intentional behaviours that protect the new child within a family unit.  I have so much to be thankful for.

Yet even as I am awash in the joy and newness of new birth, I know there are times when even our best is insufficient.  Times when a baby cries with tummy ache, or when a mother is overwhelmed with tiredness.  Times when the needs of other children must be attended to.  Times when we seek medical expertise for health problems that can sap us of energy.  Times when our best is simply not good enough.


An abiding lesson that I have learnt from my contact over the years with newly born babies; my own children, the children of my friends and clients, and my grand-children, is the picture of the baby's craving for mother's milk.  This analogy was drawn by Peter: "Like newborn infants, long for the pure, spiritual milk, so that by it you may grow."  (1Peter 2:2) 

In the same way as the newborn infant craves her mother's milk, and cannot be satisfied without it, the skill of the midwife is to work in harmony with this primal natural process.

Women's rights in childbearing

I took a consultation paper on birth registration, and the latest issue of MIDIRS with me in the plane yesterday.  The flight from Melbourne to Brisbane takes about two hours, which fits well with my capacity to stay focused on a topic. 

The issues around women's rights in childbearing have been promoted by many writers and film makers.  A multi-disciplinary international conference on human rights in childbirth was held in the Netherlands a few months ago, spurred on by outrage at developments in Hungary with relation to  criminal proceedings against doctor-midwife Agnes Gereb.

Australian birthing activists are planning to meet in Sydney next month for a special meeting on Childbirth and the Law.

Who decides how and where a baby is born? Who bears the risks of childbirth? What legal rights do women have to choose how they give birth? These are just a few of the issues that will be discussed at the upcoming Childbirth and Law Forum on Friday 12 October 2012 at Riverside Theatre, Parramatta.

The Childbirth and Law Forum will begin at 2pm with presentations from  two speakers who will discuss the legal issues facing childbirth today in Australia. (Homebirth Australia press release)

It seems that women and childbirth activists in the UK are learning how to demand homebirth services within their public maternity care system.  Barrister Elizabeth Prochaska wrote:

A recent case of mine shows that it is worth fighting decisions to refuse to provide a home birth (even at a late stage in pregnancy).  A large London hospital suspended its home birth service for a month due to staff shortages and informed women who had planned home births that they would be transferred to hospital by ambulance regardless of whether or not they consented to transfer.  AIMS put a coupe in contact with me who had been promised a home birth by the hospital.  With only a few weeks before their baby was due, they decided to threaten legal action, relying on a legitimate expectation and the Ternovsky case. The hospital rapidly backed down and agreed to provide independent midwives to attend all the affected women at home. (Prochaska E. AIMS Journal, vol 24, no2, 2012, pp6-7.)

The debate around women's rights in childbearing are confused and complicated by the whole spectrum of risk and professional duty of care.  Women in Australia who are within cooee [an Aussie slang word for reasonable distance] of a publicly funded homebirth service will often experience extremely narrow definitions of wellness, or exclusion criteria, which make many ineligible for homebirth.  For example, a woman who declines a test, such as ultrasound, or glucose, or group B Streptococcus, may be unacceptable for homebirth.  Similarly a woman who indicates that she plans to decline active management of the third stage, can be excluded.

In these cases it seems fanciful to argue women's rights, when the hospital simply uses narrow risk management protocols to exclude them.  They are no longer 'low risk'.

Similarly, the options for women who have had one or more previous caesarean births, are woefully inadequate.  A woman planning vbac is ideally cared for in her home as her labour establishes, with a known and experienced midwife in attendance.  The decisions about home or hospital birth can be made as labour progresses (or doesn't, as the case may be). 

Midwifery services today use the term 'evidence based' without challenge.  The exclusion of women from birth centres and homebirth programs is considered 'evidence based'.  Rarely does anyone ask, "what evidence is that?"

A recent update of the Cochrane review , the centre of excellence in medical evidence, states:

There is no strong evidence from randomised trials to favour either planned hospital birth or planned home birth for low-risk pregnant women. ...

Benefits and harms of planned hospital birth compared with planned home birth for low-risk pregnant women

Most pregnancies among healthy women are normal, and most births could take place without unnecessary medical intervention. However, it is not possible to predict with certainty that absolutely no complications will occur in the course of a birth. Thus, in many countries it is believed that the safest option for all women is to give birth at hospital. In a few countries it is believed that as long as the woman is followed during pregnancy and assisted by a midwife during birth, transfer between home and hospital, if needed, is uncomplicated. In these countries home birth is an integrated part of maternity care. It seems increasingly clear that impatience and easy access to many medical procedures at hospital may lead to increased levels of intervention which in turn may lead to new interventions and finally to unnecessary complications. [emphasis added] In a planned home birth assisted by an experienced midwife with collaborative medical back up in case transfer should be necessary these drawbacks are avoided while the benefit of access to medical intervention when needed is maintained. Increasingly better observational studies suggest that planned hospital birth is not any safer than planned home birth assisted by an experienced midwife with collaborative medical back up, but may lead to more interventions and more complications. 

An article in MIDIRS that prompted my thoughts today is titled Women's Rights in Childbearing, by Nadine Edwards.  Nadine is vice-chair of the UK maternity organisation AIMS, and a director of the Pregnancy and Parents Centre, Edinburgh.

In 'Women's rights in childbearing'  (Edwards, 2012), there is considerable focus on the rights of women to give birth at home unattended: free birth.  The article reports that  UK authorities support a woman's 'right' to give birth "without medical or professional help. ... it is legal as long as the birth is not attended or the responsibility for care is assumed or undertaken by an unqualified individual. ... the woman assumes responsibility for her birth."

Recently a young woman spoke to me about being asked by a woman to attend birth, as a doula, without a midwife being present.  The limits of responsibility in such a situation are in no way defined or clear.  It's clear to me that the Australian authorities will jump at the opportunity to close any opportunity for unregulated birth attendants, whatever they call themselves, to replace the highly regulated midwife.  Unfortunately it will take adverse outcomes to test the limits of women's rights.

More evidence ...

... demanding action.

For many years the buzz word in maternity care has been 'evidence'.  'Evidence-based' maternity care guidelines can be found everywhere. 

Application of the evidence into mainstream maternity care is quite another matter.

From my perspective, it's great to see another piece of reliable evidence supporting midwifery continuity of care /caseload midwifery/ one-to-one midwifery.  This evidence is published in a respected professional journal, BJOG, and International Journal of Obstetrics and Gynaecology, reporting on research carried out under the strict rules of randomised controlled trials, by the La Trobe University team of midwifery academics, led by Associate Professor Helen McLachlan.

The title of the paper is:
Effects of continuity of care by a primary midwife (caseload midwifery) on caesarean section rates in women of low obstetric risk: the COSMOS randomised controlled trial.
Authors: McLachlan et al, BJOG (2012).


The team of authors of this paper includes midwife academics who were prominent in the 'Team Midwifery' research from LaTrobe Uni more than a decade ago.  'Team midwifery' was adopted into many mainstream maternity units, in an attempt to reduce the huge number of midwives who provided care for individual women during their prenatal, intranatal, and postnatal experience.  Women were allocated to the 'Green team' or the 'Pink team'.  Midwives work ordinary hospital nursing shifts.  Women under 'team midwifery' are usually attended in labour by midwives who are strangers. 

Two papers addressing Team Midwifery, authored by Professor Ulla Waldenstrom and others, and Mary-Anne Biro and others in 2000 in the journal BIRTH presented the research findings, and a commentary was written by Karyn Kaufman.  Kaufman, a midwife academic and a member of a community-based midwifery practice in Canada highlighted in her review the lack of difference between the control or ‘standard care’ and the intervention, team midwifery.  Kaufman commented that “midwifery care that follows strict medical protocols is not the same as midwifery care that is enacted from a philosophy of normal birth and is individually negotiated with labouring women.”  This statement sounds logical, yet many Australian midwives at the time may not have realised that midwifery care for well women can be enacted from a philosophy of normal birth.

The primary outcome of the continuity of care by a primary midwife (caseload midwifery) trial is that

"In settings with a relatively high baseline caesarean section rate, caseload midwifery for women at low obstetric risk shows promise for reducing caesarean births."  

Besides having fewer caesareans, women allocated to 'caseload' were more likely to have a spontaneous vaginal birth, less likely to have epidural or episiotomy, and their babies were less likely to be taken to the special care nursery than those who received standard care.  

Good for mother, good for baby.

Good for the midwife, too.

In the highly formal language of academia, the authors have boldly come to the conclusion that the midwives with caseloads "can make a difference by reducing the caesarean section rate."

When a reduced likelihood of caesarean can be demonstrated for women at low risk of complications, it's time for the midwifery profession to celebrate.  

Evidence demands action.

This is reliable evidence.

This research was carried out under strict controls.

Midwives and maternity services must be challenged to apply the evidence to practice.  The usual practise of midwifery should be in a caseload model, working autonomously in their scope of practice to promote, protect and support physiological processes in birth whenever possible ('Plan A').  Not as shiftworker nurses in hospitals who work as assistants to obstetricians.  

Only when midwives are willing to take action on evidence will we see improvements in birth outcomes: healthier mothers and babies.