old-style midwifery

I have tried to capture the essence of the 'extraordinary'

The old-style ‘independent’ midwife, who has learnt autonomy and independence in practice and in decision-making from experience as the responsible primary maternity care provider for an individual woman, knows the value of working quietly and without fuss, in harmony with natural physiological processes, and enabling ordinary women to access their extraordinary strength and health in giving birth and caring for their babies.

[From APMA Blog]



Last week I was writing about the changes that I see taking place around me in Australian midwifery, as government and professional regulators make their efforts to improve the status quo - a task that all modern societies entrust to expert decision-making processes.

Other midwifery matters on my mind at present are the review of a university study module on postnatal midwifery care, for which I am tutor and marker, and a liability report I was asked to write in relation to a case in which a baby has cerebral palsy. These themes have influenced my thinking, as I engage with women in my care, at many points on the pregnancy-childbirth continuum.

Younger midwives may object to my comparing of 'old-style' midwifery with 'new'.  But the truth as I understand it is that midwifery today should be essentially the same at the primary care level as midwifery (by whatever name) in all societies and all times.  The new midwife who understands and is committed to 'old-style' midwifery, with linkages to the best and most effective medical services when needed, is practising midwifery well.

Since 'being' a pregnant-childbearing woman is not an illness, and never has been, the midwife with woman in the childbearing-nurturing time of that woman's life sees beyond the current fashions and time-related activities of a society.  That's what I mean by the 'old-style' midwife.

The debate around social and primary healthcare models, which aim to base all health care on the individual recipient of the care (in maternity care, the woman), compared with medical models of care that focus on illnesses or conditions, and the right treatment is readily applied to primary maternity care.  Sociologist Kerreen Reiger has contributed to this debate in The Conversation , in a commentary on 'Evidence-based medicine v alternative therapies: moving beyond virulence'. I am aware that some of my colleagues in midwifery look to alternative therapies, such as homeopathy, naturopathy, and traditional Chinese medicine in an attempt to provide a more holistic and woman-focused treatment option. This, in my mind, is not 'old-style' midwifery.

It might be 'old-style' treatment of illness, in the same way that people of previous generations concocted medicines out of plants that had medicinal properties. That 'old-style' treatment of illness has developed into the world of pharmaceuticals - a whole new terrain for discussion of ethics and power relationships in healthcare.

The basis I have for trusting 'old-style' midwifery is that the physiological and physical and psychological norms of health in the childbearing woman are consistent across time and culture. As long as it is reasonable to continue without interruption in that finely-tuned natural state, there is no better or safer way. The decisions around what is reasonable and what is unreasonable are quite different in a modern society from what our grandmothers experienced. Similarly women in Melbourne today are able to access a very different level of medical management for illness or complications than are women in tribal societies in developing parts of the world today.

'Old-style' midwifery, focused firmly on the woman in the midwife's care, together with the best available scientific, evidence based interventions when illness or complication are detected, is the recipe for best practice in primary maternity care. 

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.

maternity services survey

This is a high priority request to any readers who have had a baby in Australia since November 2010, or who hope/plan to have a baby in the near future. 

Please click HERE and follow the survey process. The survey will close midnight Sunday the 4th of March 2012. [The survey will accept one response only from an individual]

Please tell the survey why you want to have your own midwife, plan homebirth, promote normal birth, or whatever is important to you. Also, if you have friends who you think could spare 10 minutes to complete the survey, please pass it on to them.

Background
In 2010 the Australian Government introduced a series of reforms to improve access and choice in maternity services for women in Australia. The Australian Government Department of Health and Ageing (DoHA) is now seeking feedback from women on what their experiences have been with recent maternity service arrangements and whether they are aware of the reforms that are in place. Your important feedback will help to shape the future of maternity services in Australia.
Healthcare Management Advisors (HMA) has been engaged by DoHA as an independent organisation to conduct and collate the results of this short survey (3-5 minutes). All your responses will come directly to HMA and will be summarised so as not to be identifiable in any reporting. A report will be provided to DoHA for consideration by the Minister for Health regarding future arrangements for maternity services in Australia.
This short survey can be accessed through the following link http://www.surveymonkey.com/s/HMAmaternitysurvey The survey will be open until Sunday the 4th of March 2012. Please contact Justine Irving at HMA on justineirving@hma.com.au or (08) 8168 8000 if you have any questions or if you would like to complete the short survey over the phone or in hard copy. On completion of the online survey you will be directed to the Australian Government Maternity Services Reform website (www.health.gov.au/maternity) where you can find additional information on these reforms.

www.babyfriendly.org.au

The Australian Baby Friendly Health Initiative – NEW WEBSITE - now live!

You are invited to visit www.babyfriendly.org.au to hear an introduction by Tara Moss the UNICEF Australia Patron for Breastfeeding and BFHI. You can also view short clips from the new BFHI DVD about each of the Ten Steps to Successful Breastfeeding.

The website includes information about why and how your facility can ‘Go Baby Friendly’ and a list of Baby Friendly accredited hospitals in Australia.

Launch Special! The first 50 people to subscribe as a Baby Friendly Supporter will receive a copy of the new BFHI DVD signed by Tara Moss. The DVD is due to be launched in May 2012.

Seeking Testimonials: If you, or someone you know, has a Baby Friendly story or photo and are happy to share this on the website, please contact the BFHI Manager, Rachel Ford, on 1300 360 480 or info@babyfriendly.org.au. We are particularly interested in stories about working or birthing in a Baby Friendly hospital, undergoing Baby Friendly accreditation, or what Baby Friendly means to you.

A big thank you to UNICEF Australia for the hours of work and consultation that went into designing and developing the website, in particular the careful sourcing of all the fabulous images! Thanks also to the BFHI National Advisory Committee for their contributions and advice.
Ann Kinnear
Executive Officer
Australian College of Midwives

Welcome!

Our family has welcomed a beautiful little girl, Amélie Grace, who was born to Miriam and Neville yesterday.

Those who have the privilege of observing the work of birth will marvel at the miracles that are repeated over and over again. Here's a picture of the miracle of the newborn baby searching for, and finding, the breast. We call it the breast crawl. It's awesome!

Planning for birth

I have updated my little booklet, Planning for birth, which I have used for many years as a handout for women who visit me, making inquiries about having a baby, and for midwives and students of midwifery.

This booklet is self-published, and copies are printed as required. Readers who would like like a .pdf copy, please request by email joy@aitex.com.au [I have not hyperlinked this email address, as that may invite spam] I am happy to share my work. If you want to use copyrighted items such as the poem 'waiting' on page 8, please give reference.

waiting

You are waiting to give birth.

Your pregnancy is a statement of your wellness, life and strength.  New life is swelling your womb. 
 

You and your mate accept the gift of life with eager anticipation.

Your body tells you that change and growth are following nature’s course.   The cessation of your menstrual flow, the desire for good food and rest, the enlargement of your breasts - all external - accompany the private dreaming.

As your midwife I am committed to supporting you and your family through this wonderfully basic life event - the birth of your baby - your personal, intimate celebration of life and health.

 ©Joy Johnston

The pages of the booklet are also scanned here - 4 sheets with 2 pages per side. 

Finding a mentor - being a mentor

A mentoring agreement between two midwives can enrich and support both the mentor, and the one who is being mentored.
I have experienced this special relationship in the past two years, with a colleague who asked me to mentor her as she explored and experienced private midwifery practice as a career option for herself. During face to face meetings, phone calls, and email messages we discussed and questioned and reflected upon our shared and separate experiences as midwife, as woman, wife, mother, sister, and many other roles.

We each learnt to trust the other, and avoid defensiveness, when a question, such as "Why did you do that?", or, "... not do X" arose. Trust enables truthfulness, which leads to accountability and critical thinking, which can lead to changes in the way we behave in a given situation: the lifelong learning pattern that a midwife will always value.

I have titled this post 'finding a mentor, and being a mentor', as the midwife who is being mentored will quickly realise that she is able in turn to mentor others. The role of ‘mentor’ as it is commonly used in midwifery literature and discussion, is

mentor: a trusted friend, counselor or teacher, usually a more experienced person. ... Today mentors provide their expertise to less experienced individuals in order to help them advance their careers, enhance their education, and build their networks. [Wikipedia] 

Although there are no set ‘rules’, the following simple points may guide you in choosing a potential mentor:

• • The mentor should be a midwife who is practising or has recently practised in the scope of midwifery that you are entering; eg having a caseload 
• • In asking another midwife to be your mentor, you need to find ways in which you are able to work together, so that you are able to learn from your mentor, and she/he can observe your professional activity. This can be within a midwifery group practice, or as self employed midwives, or as volunteer members of a group, such as the local committee for the College of Midwives, or Maternity Coalition. 
• • The midwife who agrees to a mentoring agreement may ask you to do something as your side of the arrangement. She may ask you to be accountable to her, in giving regular updates on your learning goals, using the ACM MidPLUS professional development recording system. 
• • Review your situation from time to time, and be ready to become mentor.

$? What fee does a mentor charge? 

Of course there is no simple answer to that question.  A great deal of informal mentoring happens, without any fee and without being given any title, as midwives support one another within their communities. 

Sharing of skill and knowledge is a logical and accepted principle in health professional ethics.  Putting it another way, if there is insufficient sharing and passing on, that skill and knowledge will quickly be lost.

However, being a mentor requires commitment of time and interest. I have found that midwives who ask me to mentor them are happy to come to an agreement in which there is an exchange of money, and an expectation of commitment over a period of time. 


Here are a couple of examples of mentoring arrangements between midwives:

• Midwife A is an experienced independent midwife, who has established a midwifery business (or group practice) which enables other midwives to practise privately under the name of the business.  Midwife B asks A to mentor her, and comes into A's business as a partner.  The agreement between B and A's business is that B will pay an agreed percentage (eg 20%) of her earnings to A's business.  In return, B and A meet together for professional discussion each month; B is able to telephone A for direct support and advice at any time; and the advertising, book keeping, superannuation, and tax requirements of B's income are managed within A's business.  
• Midwife C is working part-time in a hospital, as she establishes her own midwifery practice.  C asks Midwife A to mentor her, but she does not want to become a partner in A's business/practice.  A and C come to an agreement that C will pay an amount for professional mentoring, and A will provide C with a receipt for that payment.  The support agreement between A and C is otherwise the same as between A and B.

Millennium Development Goals: How are we progressing with the maternity goals?

Millennium Declaration

In 2000, 189 nations made a promise to free people from extreme poverty and multiple deprivations. This pledge became the eight Millennium Development Goals to be achieved by 2015. In September 2010, the world recommitted itself to accelerate progress towards these goals.

The 8 Millennium Development Goals are:

1 Eradicate extreme poverty and hunger
2 Achieve universal primary education
3 Promote gender equality and empower women

4 Reduce child mortality

5 Improve maternal health

6 Combat HIV/AIDS, malaria and other diseases
7 Ensure environmental sustainability
8 Develop a global partnership for development

Each of these goals has a potential to improve maternity outcomes in the world's poorest countries.  Goals 4 and 5 give direct measures of maternity care.
If you would like to see the UN 2011 table summarising progress, click here.


Readers may wonder what significance the MDGs have in the context in which I practise midwifery.  Private midwifery in and around Melbourne is, surely, for a privileged minority, who are usually healthy, well educated women, and able to pay for the maternity care they choose.

This is true.

Women who plan homebirth in my practice understand that my role includes arranging transfer to hospital if complications are detected.  Well staffed and equipped maternity hospitals are within easy reach by car or ambulance, in most instances.  Availability of appropriate referral services is a key to safe and optimal outcomes, whether the referral is from planned homebirth, or from small primary maternity care units in rural towns.

Women in places where maternal mortality is high may not be within reasonable reach of emergency obstetric services; may face prohibitive costs if they do go to hospital; and often delay in seeking medical intervention.  Their bodies are often weakened by anaemia, malaria, HIV/AIDS, intestinal parasites, and other preventable conditions.  Mothers and babies die from Tetanus, because the mothers have never been vaccinated against Tetanus.   Women do not have access to acceptable family planning measures; child-brides are pregnant before their bodies are fully developed; too many women develop obstetric fistula; and the list goes on.

The challenge that I see in comparing maternity care here in Melbourne, with maternity care in some of the world's most disadvantaged settings, such as Sub-Saharan Africa, or the highlands of Papua New Guinea, is the continuing and increasing reliance on medical and surgical management of birth in the West.  This logically equates to a loss of knowledge, a loss of expertise, in working with natural processes in the childbearing continuum.  The excessive and unnecessary medicalisation of birth and everything related to maternity care, as is seen in mainstream maternity care in Melbourne, will not improve maternal or infant health in less developed countries. Melbourne hospitals are teaching doctors and midwives who will pass contemporary practices on to their students in all parts of the globe.  Melbourne, which has world-best facilities for those who need them, must set an example of best practice in protecting each woman's ability to give birth under her own amazing power - 'Plan A', unless there is a valid reason for 'Plan B'.

For decades we have seen the global impact on the lives of babies of the loss of collective confidence in breastfeeding.  Efforts to protect, promote, and support breastfeeding are required in the rich world if we want to have any impact in poorer countries.  The Baby Friendly Hospital Initiative (BFHI), which in Australia is known as the Baby Friendly Health Initiative, has the expectation of the same high standards in each of the '10 Steps to successful breastfeeding', whether the hospital provides care for those who pay big money, or those who are in low socio-economic settings.

Childbirth is not very different from breastfeeding.  The loss of confidence in natural physiological processes in childbirth, including the spontaneous onset of labour, progress in labour, giving birth without medical pain relief or physical assistance, expelling the placenta, and establishing breastfeeding, to name a few key points, needs to be recognised and rectified in Australian mainstream maternity care.  There is no safer or more reasonable way to proceed with childbirth, for most women, than to do so under the natural, hormonally-driven processes within each woman's body.  Only those for whom a valid reason to interrupt the natural processes will be better off with such intervention.

I expect any readers are likely to be already convinced of these facts, so I won't press on.   

Midwives, we carry the knowledge of normal birth!  We must value that knowledge, and hold on to the skills of working in harmony with women's natural physiological processes, whether in early labour, breastfeeding, birth, or the third stage. 

The 1996 'Care in normal birth' instruction from World Health Organisation, that
"In normal birth there should be a valid reason to interfere with the natural process" is as relevant when applied to the Millennium Development Goals, as it is in a Birth Centre in the rich world.

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.

optimal space for birthing?

There is a special interest branch within midwifery and maternity care that overlaps with design and architecture disciplines, exploring the creation of optimal spaces for birthing. I have been reminded of this field of interest, when reading a recent post by my colleague and friend Carolyn Hastie, who writes the thinkbirth blog. Carolyn refers to, and provides a link to a presentation on optimal birth spaces by Maralyn Foureur, Professor of Midwifery at the University of Technology of Sydney (UTS). I wrote in the comments to thinkbirth:

I have seen some wonderfully designed spaces in which women can give birth. I have also seen women give birth beautifully (and, I would say, optimally) in settings that would seem to contravene every goal of the optimal birthing space ideology.

The woman's own nesting, which I believe is hormonally driven more than the result of intelligent planning and preparation, seems to be the key. Nesting can include the choice of setting, as well as the choice of people who make up that woman's birthing team. Nesting also enables the woman to change her plan if her situation requires it, without losing the ability to proceed normally.

I don't want to be critical of the optimal birth space ideology.

HOWEVER ...

The reality in my world is that each birth space is often very different from what the woman had planned or wanted, yet women are able to give birth in that wonderfully spontaneous way, without any regrets.

It would be naive to imagine that a woman's home is automatically the optimal birthing space for her.

I need to do a postnatal visit now, but hope to get back to this post later, and write some more.

[Melbourne readers may know that a private hospital in Hawthorn had recently set up a beautifully designed birthing facility, which has closed its doors after just a few months' operation, because the plan was not working, and there were too few women making bookings.]


NESTING and optimal birthing conditions
Nesting is one of those normal physiological functions that everyone knows about, but rarely pays much attention to.   While researchers have for a couple of decades looked seriously at the impact of the love hormone oxytocin, and the 'fight-or-flight' adrenal hormones, on the birth and mothering behaviours of laboratory animals, nesting doesn't seem to raise research interest or dollars.

A woman anticipating the birth of her child will usually have a 'to do' list, including stocking and preparation of food and other consumables, washing and setting out baby clothes, and packing a bag for herself and her baby in preparation for a stay in hospital, or 'birth kit' items in readiness for giving birth at home.  This process of getting ready would be recognised broadly as 'nesting'.  I have known some who feel the need to clean windows, and sweep, vacuum, and dust almost obsessively in the days leading up to the labour.  This is all intentional nesting, driven mainly by the woman's intellectual grasp of the enormity of the job that lies ahead.

With the establishment of spontaneous labour, physiological nesting becomes more pronounced.  Women who thought they would like to have the other children present for the birth of their sibling will often withdraw into a secluded space.  Women who have a plan to call a trusted midwife will often call her, just to check that she is able to come when called.  Nesting can continue until the peak of first stage, often called 'transition', when the woman must give up conscious control and surrender to the work of bringing her child out of her body. 

Women who plan to go to hospital to give birth face a nesting conflict.  It goes something like this:
"If I go to hospital too early my labour might fizzle.  If I stay at home I won't want to move when the labour becomes strong."  It's their natural nesting drive that makes them want to find the place where they will give birth - not the street address, but the actual room, with its contents, and the actual people with whom she will need to communicate.

Women who are booked at a modern hospital Birth Centre, where there are well-designed birthing rooms, often experience a conflict about the availability of a room.  They know that if the rooms are all in use when they arrive, they will be admitted to a standard hospital suite.  They have heard stories about how often this might happen.  Other matters of 'nesting' concern might focus on the times of shift changes in the hospital. 

I have, on occasion, been called to a 'planned' home birth, only to find that the woman and her home show no sign of nesting.  This dysfunctional nesting is, I think, a sign that the woman's sensitivity to natural instinctive urges has been in some way shut down.  The woman's labour can continue without nesting, and the baby can be born, "ready or not!"

Returning to the initial question of this blog: is there, and what is, an optimal space for birthing?
I would refine the question further, and add the word 'physiological' - the space for medically managed care in labour and childbirth must be very different from the space that enables and supports and protects physiological processes.  Here are a few ideals for that space:

• a place that the woman has chosen to be in
• a place that the woman is happy to continue in, as labour progresses
• a place where the woman can receive care, support, and guidance from a trusted midwife, and other chosen people
• a place where the woman is able to cover windows, dim lights, and make other physical adjustments when she wishes
• a place that allows the woman to feel private and unobserved
• a place where the midwife, as the responsible professional at the time, is confident that the wellbeing of mother and baby are being protected.

As with all other basic life events, "the best laid plans of mice and men ..."  There can be no guarantees.  The only people who we can be sure will be at a birth are the mother and her baby. 

The optimal space for physiological birthing in suburban Melbourne should not be very different from the optimal space for physiological birthing for Inuit women in Nunavik in the Arctic Circle.  The type of bed or birthing pool; the colour of the walls or the pattern of the furnishings - these things can be nice, but are of little significance to the woman giving birth.  The woman's feeling of unintruded privacy, as she reaches the point of surrender, knowing that her midwife is *with* her, is the essence of optimality. 


Your comments are very welcome.

spontaneous birthing

There was no acceptable alternative; no short-cut or easy way.  The labour had established.
The young mother struggled with every surge of uterine activity.  "I can't do it!  I am too tired!", she cried in English, then lots more in another language.
If one of us had been able to step in as proxy; to labour and give birth, or even to do some of the work, and lessen her load, we would have.  Surely it's unfair that the woman has to do it all?

Each time I witness the massive effort that culminates in the unmedicated, unassisted birth of a baby - and particularly a first baby - I am in awe.   The journey that can have many unpredictable and unexpected turns in the path; many forks in the road.  At each decision point, only one way can be taken.  Is this the best way?

As midwife, I hear many voices.  The mother's body, the baby's body, my own mind, the voice of professional and scientific knowledge, and the words of others participating in the birthing journey.

When the mother's mind says "I can't do it! I'm too tired!" I can't just block my ears.

I ask, what does her body tell me?

There is power in these contractions, and I have seen progress over time.
There is strength in this young body.  Her pulse rate is steady and strong.
There is quietness in the moments of resting between contractions.
Is mother well?  At present, yes.

I know we can continue.

I ask, what does her baby's body tell me?

The baby's heart rate is strong and steady.
The contractions, although strong, do not bring any sign of distress in the baby.
The baby's station is progressing with time.
Is baby well?  At present, yes.

I know we can continue.

I ask, what does my own mind tell me?

It's the middle of the night, and my mind is also weary.
I hear the cries.  I know that she is sleep-deprived.
I seek to guide this girl who is being transformed into a mother through this rough terrain.

I will not interrupt or interfere with the amazing metamorphosis; the life-giving struggle that we are witnessing.

I ask, what does professional and scientific knowledge tell me?

Simply this: that there is no safer or more appropriate way for this baby to be brought into the world, than for the midwife to work in harmony with natural physiological processes in labour and birth.
That this woman's body is wonderfully made, that this baby's body is uniquely suited to this mother, and that the process of birth is so much more than delivery of a child from the womb to the outside world.
That the transitions which must take place shortly are best supported in strong, unmedicated birthing.

I know we can continue.

I ask, what do the others - the husband, the friend, the student - tell me?

We are working together, and I am responsible for so much.  These members of the team are looking to me for encouragement and strength.  They do not have the years of life experience that I have, and they are quietly learning to harmonise their actions with those of the labouring woman.

I know we can continue.



We moved to the birthing pool.  The pushing had been ineffective, and the voice "I can't do it, I'm too tired!" was becoming more persistent.

Then, as an expulsive urge was about to go, I saw some fine, thick black hair peep out between the labia, then disappear again.

"I can tell you what colour your baby's hair is" I said.  "Black."

We all laughed.  Babies from their people group all have black hair.


I don't know when the young mother realised that she actually could give birth, that she was giving birth.  But I know and hold onto the look of utter amazement and satisfaction as she took her child into her arms.

Thanksgiving

Me with my girls

From time to time as that special day passed I rubbed my belly, enjoying the sensation of tightening as the fundus became firm. I was as confident and ready as a 23-year-old entering motherhood for the first time could be.

For most of the week prior to this day we had gone for walks in the evening, and the tightenings had come for a while, then stopped. Each night as we went to bed I wondered, "Is this the night?" Each morning I awoke, rubbed the bump that protruded under my diaphragm, looked in the mirror at the enormity of my previously flat abdomen, and continued in waiting mode.

The special day was Thanksgiving Day in the USA. We had settled in to our home in Michigan; Noel had commenced his graduate studies in the Dairy Science department at Michigan State University; and we had been invited to join the Professor, Wayne Oxender DVM, and his partner, for our first American Thanksgiving meal.

Our hosts had prepared special food that had significance to the celebration of thanksgiving to God for preserving the lives of the Pilgrim fathers through the previous year, with food stored for the coming winter.

Decorations had been carefully made using corn husks and natural fibers. The turkey had been stuffed and was basted carefully as it roasted to perfection for many hours. I had never seen a turkey like that one. There was abundant sweet corn, sweet potatoes, and corn bread. Probably a dish of spinnach. I don't remember the details. A large bowl was set up with hot apple cider that had sticks of cinnamon floating in it. We dipped into it many times. It was sooo good!

This was a totally new culinary experience for a girl from sunny Queensland. Then pumpkin pie - who ever would have thought of using pumpkin, the staple vegetable, as a dessert? On top of the servings of pumpkin pie someone squirted fake cream out of a pressurised can - the fashion at that time. Who ever would have thought of putting cream into a pressure pac? The irony of using fake cream on this most basic of 'back to the simple life' feasts stuck in my mind, but I was too polite, too blown away, to say anything.

As I said at the start of this post, I was experiencing some tightenings which were preparatory for my labour with my first child, Miriam. That evening the labour became established, and I gave birth the following day.

The good company, good food, and totally new world that we experienced in late November 1973 prepared me for motherhood. Being surrounded by members of the veterinary profession, with their special interest in reproduction and raising of calves, was good for me. I have often reflected on that period in my life, and it has in many ways supported my efforts to work in harmony with natural physiological processes in the birth and nurture of babies in my care.

Uncertainties

bonsai Japanese Maple

Members of my family are at present dealing with major challenges as they progress along the pathway towards the birth of a child.

I am a midwife who seeks to promote, protect and support wellness and wholeness in pregnancy, birth and the nurture of a baby. This is the usual situation for most women.

I would like to especially acknowledge anyone who finds themself on an unexpected, and really unwanted (if they had been able to choose) pathway in the journey to a birth.

With this in mind, I am linking this post to the blog of my nephew Dave and his wife Petrina, whose unborn baby is being treated for heart failure. As I read through the posts at their blog I am confronted again and again with the uncertainties of this particular case. I am also thankful for the openness and clarity with which these young parents have attempted to share some of their feelings - not knowing where the journey will take them.

Most of you who read my blogs will be doing so out of your interest in midwifery.  The question to the midwife is, how can I be midwife, 'with woman', when the overwhelming focus of care and decisions that are being made are intensely medical; when the birth of this baby will almost certainly be surgical, and contact between mother and baby will almost certainly be minimal as a new team of specialists assumes care for him or her.

Any complicated pregnancy presents this challenge, to a greater or lesser degree.  Increasingly specialist medical knowledge and technology are pitting themselves against conditions that would previously have been incompatible with life - this phenomenon appears to be unstoppable from the perspective of science and medicine.  Where there is any hope of life, parents are likely to give permission for whatever is offered.

We say that every woman giving birth needs a midwife.  The midwife for a woman in a complex and challenging medical birth focuses on the woman as a whole person - not just as the carrier of a very special baby.  Many of the plans that are made by women approaching normal-physiological birth cannot be considered.  The baby's *condition*, or the *complication* take on leading roles in the story that is being played out in real time.   


If you have read this far, you might wonder why I have included a picture of a little bonsai tree from my garden.  The reason is, that in a special way, I learn lessons from tending these wonderful but fragile plants.  There is a sense of connection between a living thing and its carer, as I know that without daily care and special knowledge this tree will die.  There is such beauty in the changes that come with seasons - I had previously posted a picture of this tree in the winter, having lost its leaves.  These miniature trees offer me a special life focus, as I tend the creature, and seek to work in harmony with the Creator.

Becoming parents

The focus of the midwife is, without doubt, the woman.  Midwife means, literally, 'with woman'.

But the woman is much more than the bearer of a child.  The woman becomes a mother, in the context of a family, and the child is nurtured within her or his family.  The child grows physically, emotionally, and spiritually as food, shelter, and protection are provided by both mother and father, and values are taught from before birth.  Focus on becoming parents is included in the work of the midwife, and extends well beyond the scope of midwifery.

I have recently received a copy of a new book, "Becoming Us, The Essential Relationship Guide for Parents" by Elly Taylor.   I am looking forward to reading it.

It's available in all good book shops, ABC shops and on-line.

For more, see the linked website Parent Support Online.

what will the students do ...

... after graduation?

New graduate midwives in Victoria are facing great difficulties in securing employment.

A facebook site has been set up to support student midwives who do not have a 'graduate year' position available to them. The fb group lists 44 as students without a grad year, and a couple of hundred 'friends', all since the site was created a week or so ago.

what will the students think?

A few weeks ago I wrote about the interim Position Statement on Homebirth that appeared , with endorsement, on the website of the statutory body. The Position Statement and associated documents had been prepared by the College of Midwives.

Today I attended a meeting of members of the College, at which I and other members took the opportunity to speak about our concerns around these documents.

mother-midwife

 The midwifery I practise is inextricably linked to my being a mother, and being a mother to my family cannot be separated from midwifery as I know it.

Although I learnt the basics of midwifery in the classroom and wards of the Royal Women's Hospital, I consolidated my learning, and became convinced of my identity as a mother-midwife during the months and years of pregnancy, giving birth, breastfeeding, and nurturing my four children.

This precious picture shows our two girls, happily breastfeeding their dollies.  The year was 1977, when their brother was a baby. 

Further down the page is a pic taken this week, of Bec with her baby James at her breast, in that blissful milky dream-state.

This past week has been a very special one for our family, as we have experienced the inevitable separation that comes with death of a loved one.  Yesterday my husband's mother, Lily Johnston, was buried, surrounded by her loving family.    Grandma had her 99th birthday earlier this year.

Being mother-midwife to my family requires a special trust between me and the young women.  I cannot presume that any woman will accept the principles that I follow; I cannot expect, nor would I want, uncritical adherance to a professional care plan that is not widely understood in our community. 

The ability of a particular woman in bearing and nurturing a child is not a fixed or definable matter.  The 'power-passage-passenger-psyche' equation is tested as the mystery of labour proceeds.  A woman who is able to continue and make good progress does not need to consider other options.  'Plan A' is, for her, the only plan to be considered.

A woman whose progress is slow, or who is unable to accept the pain she experiences, or whose baby's heart sounds tell us that he is not receiving enough blood during the contractions - this woman is confronted with complex and often challenging choices and decisions: 'Plan B'.

Being mother-midwife often takes me into realms of uncertainty. 

Midwife Medicare Provider Number

The Department of Human Services Medicare Australia has allocated a Provider Number to Mrs Joyce Johnston [that's me, the villagemidwife], Aitex Private Midwifery Services, at 25 Eley Rd Blackburn South, Victoria 3130, effective 22/09/2011. The Provider Number is for the purpose of rendering accounts for approved Medicare services performed and for requesting certain diagnostic imaging and pathology services while working in a private capacity.

As a Medicare-authorised midwife, there is scheduled fee for each item, from which rebates are calculated [variation in amount payable depends on a person's safety net].  For example:

Living with uncertainty

I arrived at the home of a woman in labour, and everything I saw and knew about this woman and her baby told me that the birth was imminent. After greeting her - she was in the shower - I went through the routine setting out of my equipment in readiness and connecting the oxygen cylinder to the flow meter.

Three hours later, there was no baby. No apparent problem with either mother or baby. A rim of cervix, an undescended fetal head, ... Mother asked me if I had brought my knitting. No - I really didn't expect to be waiting around long enough. It's a second baby, after all.

Mums Matter!

The Australian Private Midwives Association (APMA) has just launched an on-line campaign, called Mums Matter!