the importance of trust

I (Joy Johnston, aka villagemidwife - see note at the end of this post) often say to women in my care, "I need to trust you, and you need to trust me."

This sounds reasonable to me, particularly within the context of primary maternity care that spans the pre-, intra- and postnatal periods.  While midwifery is not rocket science, the commitment a woman and her family make to a new baby is perhaps the most far-reaching investment they will ever make.  Trust is something to value: it's not lightly given; it's not easily won; and once won it can be lost.  I can not assume that a woman in my care is trusting me, and she may not know if I am trusting her.  This is the case especially when difficult decisions need to be made: when I am asking the woman to trust my professional judgment and advice in order to protect the wellbeing of the mother or child.

According to contemporary thinking, midwives and women engage in a partnership that is based on reciprocity and trust (a phrase coined, as far as I know, by sociologist-academic Karen Lane.)  It's a two-way relationship.  It's a relationship that builds over time, and is tried and potentially strengthened as each woman and her midwife navigate the unique terrain that each pregnancy-birthing episode offers.

Partnership should not be seen as an idealistic notion: the current internationally accepted definition of the midwife includes:

... The midwife is recognised as a responsible and accountable professional who works in partnership with women to give the necessary support, care and advice during pregnancy, labour and the postpartum period, to conduct births on the midwife’s own responsibility and to provide care for the newborn and the infant.... (International Confederation of Midwives)

The stark reality of life is that some people find it difficult to trust anyone, while others give away their trust lightly to anyone who sounds as though they know what they are talking about.  Most people fit somewhere between the two extremes.  The definition of the midwife is looking at the big picture, while the experience many women have with a midwife or midwives may be far removed from any sense of working in partnership.  Similarly, midwives who provide continuity for their own caseload of women may find themselves in situations in which the sense of partnership is sub-optimal.

A young midwife told me she felt that a woman in her care does not trust her because she has had only a few years' midwifery experience.  A couple of comments that the woman made left the midwife wondering if she was able to continue as midwife. 

That discussion prompted me to think a lot about what it means to trust, and the importance of trust in midwifery - in the processes of decision-making that a midwife uses.

I do not, ultimately, trust birth.  Birth, like any other part of life, is able to be complicated by disease and corruption.  The midwife's role in maternity care is to firstly work in harmony with awesome natural processes, and secondly to recognise complication and intervene to prevent loss of life or damage. If I trusted birth there would be no need to work as a midwife.  I would simply accept 'Que sera sera' (what will be will be).

I have reflected on the many women for whom I have provided midwifery services over the years, and wondered if my statement, "I need to trust you, and you need to trust me" is true.

Many women have gone through the birthing process with minimal intrusion or action by me: my job is to be 'with woman': to watch and occasionally give support, then fill out the paperwork.  In almost all of these cases there has been, I believe, a working partnership based on reciprocity and trust.  The woman who is trusting her midwife is able to surrender to the work of her body when the time comes.

Some women have needed more than I have been able to give them in community based midwifery care, and we have transferred care to a hospital maternity service.  I expect that in some of these situations the woman's ability to trust me as her midwife, or to trust herself as the birth-giver, has been less than optimal.  In some, my ability to trust myself as midwife, or the woman as the birth-giver has been compromised.  At times I may have been too weary, or emotionally drained, or fearful, or ...




Spring 2013

Tomorrow is the official start of Spring in the southern hemisphere.  It's exciting to see the tender young leaves on deciduous trees, and flowers on the fruit trees.

Spring 2013: Bonsai Japanese Maple and azalea

The signs of new life are within the natural processes that offer endless wonder and thrill to those who are ready to see.

Midwifery has taught me to respect and work in harmony with the natural processes as much as is possible.

These little bonsai trees have been in my care for several years. 






postscript...
Don't believe everything you see on the internet!
I began today with "I (Joy Johnston, aka villagemidwife...)" because, for some reason Blogger (the program I use to write this and other blogs) thinks I have changed my name. Probably my own fault - I told my sister I would help her get started writing a blog, and somehow Blogger now thinks that I am my sister - Barbara Clark. Everything I have written is now attributed to her, so I need to either find out how to get into my blogger profile and change my 'name', or get used to writing under a pseudonym. I have followed the instructions to go to Blogger profile, but keep getting a message "oops that didn't go well"!

I'm just venting, but if you have a suggestion for fixing it, I'm keen to get it sorted out! XXjoy

pps
Thanks Paul for fixing it.

safer and better systems of care

with my first baby 1973

Recently I have spent considerable time reflecting upon and writing about situations in which midwives face complaints of serious professional misconduct after attending home births.

See articles at the MiPP blog

Many of the complaints (notifications) that I am aware of relate to situations in which midwives attend women who have specific risk features of their pregnancy, such as having had caesarean surgery, or being classified as 'post mature', or having a breech birth or twins, for birth at home.

I do not want to seem to be guiding midwives to encourage 'at risk' women to see home birth as their only option. In my experience, a woman with twins, or breech presentation, or birth after caesarean, who is clear that she intends to hold onto 'Plan A' unless a valid reason is given for intervention whether she is at home or goes to hospital (with her midwife) to give birth; this woman will make an informed decision that she believes is in the best interests of her baby, her family, and her own wellbeing. This woman is enabled to take responsibility for her family's social, emotional, and physical health in a new way, in a special partnership with her midwife.

My personal approach to twins and breech births, after appropriate discussion and consultation, is to try to arrange support for a physiologically normal, unmanaged birth in a public hospital that has capacity for emergency obstetric intervention, if the woman believes that is the best way at the time of labour.

 This is not a simple task. It opens the door to a clash of opinion - medical vs social - in each situation. I wrote about that a few years ago - "Why bother coming here if you won't let us manage you the way we think is best?" - when a mother with twins near term followed my advice, and presented at the antenatal clinic of a large public hospital. She was told she had no option other than elective (scheduled) caesarean. The first baby was presenting breech. It's probably no surprise to readers that that mother rejected the advice of the big, well-equipped and well-staffed, public maternity hospital. We were able to engage the services of a smaller suburban public maternity hospital, and the babies were born one morning without incident, and the family returned home that afternoon - see Drive through birthing.

Another mother in my care gave birth to her twins at home. It was only after the first baby had been born, and the mother told me she was having contractions again that she placed her hand on her belly and said to me "Joy there's a lump here. Could it be another baby?" Yes, it could, and it was. By the time I had changed my gloves the second baby was ready to be born - beautifully!

Another mother in my care gave birth to her twins in hospital. The labour was powerful; mother knelt on the bed, and the first baby slipped out into my hands, cried, and went into mother's welcoming arms. The cord was clamped and cut to prevent any twin-to-twin transfusion. The mother's contractions returned quickly and intensely, and she maintained her crouched position, and passed the first baby to his dad. With the next contraction the second baby was born, about 6 minutes after his brother, with the placenta. The placenta had separated from the uterus (abbrupted) after the first birth and the second twin's life was immediately in danger as he had no oxygen supply. He needed to be born quickly, and he was. He revived spontaneously, without difficulty.

In telling this story, I am highlighting a situation in which the urgency for birth can be escalated in an instant, and specific action needed to protect, in this instance, a baby's life. After the birth of the first baby it is usual for the midwife or doctor to palpate the mother's abdomen to check the position of the second twin, and listen to the heart beat of the second twin. The mother, in this instance, refused to go onto her back, and proceeded very quickly, under natural intuitive knowing, to 'eject' the second twin. Had she been a compliant 'patient', and done as asked, and I believe it is possible that her baby's birth may have been delayed, with obvious negative consequences.

On the other hand, had there been no internal pressure to get that baby born, we would possibly have heard the slowing heart rate as the baby's oxygen supply quickly depleted, and an obstetric intervention to extract the baby would have been attempted. It's not helpful to speculate or ask 'what would have happened if?'. In this case the mother's decision to refuse a managed birth, which would have included epidural, was probably the factor that saved her baby's life, because she was able to do the job spontaneously.

I am very distressed when women with twin pregnancies, or babies presenting breech, and their midwives, are so unable to trust hospital care that they see home as the only option. Home or hospital, spontaneous, managed, or surgical, there are no guarantees. The mother's choice of home or hospital for the birth of her babies is her choice, and she will face different challenges with each pathway.

“... We must stop blaming individuals and put much greater effort into making our systems of care safer and better” (ACSQHC National Action Plan, 2001). 

The National Midwifery Guidelines for Consultation and Referral (ACM 2008) (the Guidelines) categorise women with twins and breeches as being ‘C’ (transfer). It is important to understand the place of the Guidelines in contemporary midwifery, and why after appropriate consultation, a woman and her midwife may chose to continue with the plan for homebirth.

The Guidelines were designed primarily for use across mainstream maternity services, outlining a risk management process by which midwives could act either autonomously, or in professional consultation with other maternity care providers, or by initiating transfer of care to a more appropriate maternity service. The Guidelines do not deal with situations in which women make an informed decision to seek out private midwifery services for home birth. The Guidelines do not deal with situations in which women choose care which is outside that which is recommended by the Guidelines, or by individual maternity care providers.

The Guidelines, in the preamble, indicate the purpose of these Guidelines, to address a significant gap that existed prior to their development, in helping “maternity services to meet national policy priorities aimed at improving the quality and safety of health care. When the Australian Council for Safety and Quality in Health Care launched its National Action Plan in 2001, its Chair Professor Bruce Barraclough argued that improving the safety and quality of patient care is one of the most important challenges facing health professionals: “... We must stop blaming individuals and put much greater effort into making our systems of care safer and better” (p 5) (emphasis added)

Systems of care that are safer and better than whatever Professor Barraclough referred to, and that are better than the system that told a mother "Why bother coming here if you won't let us manage you the way we think is best?", are systems that accept different levels of decision-making by different people.  A mother who values the spontaneous work of her own body in giving birth, unmedicated, to her babies, is a mother who the system needs to respect, and work hard to accommodate.

Systems of care that are safe and good for women and their babies will accept, at every level - not just the so-called 'low-risk' birth - that “Childbirth is a social and emotional event and is an essential part of family life. The care given should take into consideration the individual woman’s cultural and social needs." ICM Position Statement on Home Birth.

more thoughts on the birthing space

I have appreciated the recent thought-provoking discussion in connection with the previous post in this blog, which is also linked to Carolyn Hastie's thinkbirth blog.

In the past couple of weeks I have attended three births; two at home and one in hospital. These three mothers were 'first timers'; primipara; a special category worthy of consideration in any maternity setting.

Picture this scene:

A woman is labouring strongly and consistently in an inflated birthing pool, set up in her home.  It's 2 or 3 in the morning, the 'wee hours', when everyone is overcome by weariness.  Her man, whose sleep was interrupted by early labour the previous night, is asleep on a couch.  The midwife is nearby - within reach but dropping off to sleep between contractions, occasionally mumbling words of encouragement.  The student midwife is stretched out on another couch. There is a little light from a lamp or candle; the birthing space is quiet except for the sounds of the labour.  

After some time, the woman's sounds become deeper.  Her midwife encourages her "let your baby come down deep in your body; feel the fullness; you're doing well", and listens to the fetal heart after a contraction.  The woman does not notice that the 'period pain' she had been experiencing has gone.  In fact she has stopped thinking about her labour and has surrendered to the work that her body is doing.

By the time the early signs of daylight are peeping through the cracks in the blinds, the urge to push has become strong.  Daddy-to-be and student midwife are awake; midwife is awake and ready; and mother gives birth, through the water, to her first child.  Mother and child complete the mysterious dance of birth, as baby searches for the breast, and the placenta is expelled.

Today I would like to reflect on recent primipara births, and (without identifying individual women) discuss how the birthing space has supported these births. In the past 18 months, approximately, I have attended 10 women giving birth for the first time. 

Before looking at the birthing spaces, here is an overview of these births.  Of the 10 women:

• 10 came into spontaneous labour; which became strong as the night progressed (there's something special about night and birth!)
• 5 gave birth in water: 4 at home; 1 at hospital
• 2 planned hospital birth; both gave birth spontaneously to healthy babies
• 8 planned home birth
• 5 gave birth at home to healthy babies, without complication
• 3 who planned home birth transferred from home to hospital in labour
• 2 proceeded to spontaneous unmedicated births of healthy babies
• 1 was delivered of a healthy baby by emergency Caesarean surgery

The ages of these women ranged from 24 to 37.
The length of gestation ranged from 36 to less than 42 weeks.
The weights of these babies ranged from 2670g to 4250g.
All babies breastfed from birth.
The estimated blood loss for the 9 women who gave birth spontaneously ranged from 100 to 600ml.


I want to make a point here, which may be obvious to some, yet others may find it a challenging statement in the maternity environment in Australia.
Place of birth - home or hospital - is not a measure of good midwifery care.
Yet the decision to plan homebirth is a huge statement of intent, by the woman, that her plan is for spontaneous, unassisted, unmedicated birth.  Those who plan homebirth with an experienced midwife are able, I believe, to proceed down the path of physiological birth if that is feasible, with a high degree of safety.  Those who plan homebirth, then make an informed decision to transfer their care to hospital because there is an indication - a valid reason - are also able to protect their ability to give birth in harmony with the natural, hormonal, physiological processes that direct labour, birth, and the baby's transition from the womb to the outside world. 

In my previous discussion on birthing spaces I wrote about the physiological phenomenon of *Nesting*.  Understanding normal birth in terms of nesting, as the woman progresses under the influence of an amazing cocktail of hormones, provides a key to the mysteries of birthing.  Nesting supported each of these 10 women, as they came into spontaneous labour.  Nesting supported the three who made a decision in labour to move from home to hospital, and obtain special medical intervention that had become necessary for them.  Nesting supported the choice of position for birth, whether kneeling beside the bed, or squatting in the birth pool, or lying on the bed.

Cessation of nesting happens, I think, when the woman is able to surrender to the huge expulsive urges within her body.  Baby is "coming, ready or not".  Night time and weariness enables this transition to occur without question.  The woman, and her personal support team, have given up trying to understand what's going on; to do it the way they were taught in class.  The midwife is skilled at keeping watch, guiding when needed, without taking control from the woman.

The essential elements of the space for optimal birthing are few.  As long as the woman is able to proceed without interruption; as long as the woman is able to trust her midwife; as long as the woman and her support team are able to hold confidence in the process of birthing ...

... a baby is born.

It just happens.



Your comments are, of course, welcome.