Strengthening Midwifery in PNG

Giving birth and being born is dangerous in Papua New Guinea.

According to the National Department of Health Ministerial Taskforce on Maternal Health in Papua New Guinea the staggering rate of maternal mortality in PNG is a national emergency.

Every day, at least five women die of preventable childbirth related causes. Sixty per cent of childbearing women do not have access to skilled birth attendants and because there are only 270 registered midwives in the whole country, outside of the understaffed and under resourced regional hospitals, maternity and newborn care falls on the shoulders of community health workers and nurses.

In  September 2000, Papua New Guinea committed to combat poverty, hunger, disease, illiteracy, environmental degradation and discrimination against women and signed the United Nations Millenium Declaration, along with the other 190 UN member states. Eight Millenium Development Goals  were derived from this declaaration with specific targets and indicators. The PNG National Department of Health is targetting the 4th (reduction of infant mortality) and fifth goal (reduction in maternal mortality).

Midwives are internationally recognised as the number one primary health care professional for optimal safety for mothers and babies at birth. Even though there is recogntion of the vital role of midwives in optimising maternal and infant wellbeing and thereby reducing maternal mortality and morbidity in Papua New Guinea, the capacity to produce midwives too low and the number of midwives has remained stagnant. The midwifery workforce is aging and the registered midwives, few as they are, are rapidly approaching retirement.  Over the last five years, reports on the state of Midwifery Education and Maternal Health together with the National Health Plan have all focussed on increasing the midwifery workforce with the aim of having a midwife in every health centre and a skilled birth attendant for every childbearing women.

The reality is harsh. Too many women. A failing health system. Not enough midwives.

A sobering article in the Sydney Morning Herald in 2009 captured the issues and conditions succinctly on this date two years ago. Those issues and conditions are unchanged or worse.

Against this backdrop, the National Government of Papua New Guinea has partnered with the Australian Government to strengthen midwifery and capacity build the existing educational systems. Eight midwives started a month ago to work in pairs in four university programs with the educators and students to ensure the PNG National Standards and Competencies are achieved.

I'm fortunate to be one of the midwives, based at Pacific Adventist University (PAU) and working clinically with students and educators in the women and babies wing of Port Moresby Hospital.

The midwifery facilitation team, minus one and plus two!
From right to left Sue Englend (visiting Port Moresby), Lois Berry (based at Madang) Tarryn Sharp and her daughter Willoughby (PAU), Marie Treloar (based at Goroka) Alison Moores (University of PNG at Port Moresby), Glenda Gleeson (Mandang) Annie Yates (the Kiwi: University of PNG) and yours truly (PAU).  Missing from the photo is Heather Gulliver, who is also at Goroka with Marie.

Today, there was another big step in the right direction of strengthening midwifery in PNG.

The PNG Midwifery Society had their inaugural meeting in the conference room of the women and babies wing of the Port Moresby Hospital.

Fifty one midwives, nurses with midwifery education (unregistered) and student midwives crowded into the conference room to discuss professional midwifery matters.

Student midwives from PAU.

We booked a bus to bring the students and educators from PA University (about 30 minutes away from the hospital) and take them home again after the meeting. The students loved the experience. A very new experience for everybody.

The students are great fun and keen to learn. The educators are amazing people who are very welcoming and want their programs to meet the profession's needs and the Council's regulations. The midwives are appreciative of the students' work on clinical days as the midwifery workforce is scanty and the workload is huge. There is a lot to do to get things right in PNG.

Following the business of the meeting, the buzz was electric as the society member's shared food and conversation

                                                           

As part of the Australian College of Midwives committment to supporting and strengthening midwifery in our closest neighbour nation, four members of the society, two from Port Moresby and two from Goroka have been sponsored by the College to attend the Biennial Australian College of Midwives Conference in Sydney. Another initiative in strengthening midwifery in PNG is the  International Midwives Twinning Project. Two members of the PNG society are being sponsored by the Australian College of Midwives to go to the Hague, with two Australian College members to discuss and explore professional matters at the end of the month.

We know that when there is a strong and autonomous midwifery profession, mothers and their babies do well. The PNG Midwifery Society has the potential to play an enormous role in strengthening midwifery and creating a proud and powerful professional group for midwives, which in turn, creates a safety net for the  mothers and newborns of PNG.


Judging by today's conversation and the turn out for the meeting, the Society is well and truly up for the job!

Compassion hurts

The massacre of young people in Norway has shocked and distressed me. I know I am not alone in feeling these emotions. My heart goes out to all those youngsters who survived as they now process the loss of their friends and the feelings of guilt that comes with surviving such unfathomable horror when others didn't. I have been reading all the reports and stories, quite compulsively I realised. I was surprised by my compulsion and became aware that I'm trying to get some sense of where that cold, calculating killer was coming from; what enabled him to mercilessly and methodically shoot scores of young people. 

I read that this killer lived with his mother. As a midwife, my life has been dedicated to helping women, their partners and babies connect, knowing that our primary relationship(s) set the stage for our future health and well-being in every aspect of life.  I wondered how his mother was feeling. There was no mention of his father or any other family member in the news items. 

My information about the horrible events in Norway have come from individuals and links posted on Twitter. I have read the various newspaper reports that were linked on twitter. As the information trickled through the net, painting the picture of the events unfolding in Norway, I couldn't get my head around the way that the killer set off the bomb in Oslo, then travelled to a small island where teenagers were on a summer camp and slaughtered so many of them.  Why????

A link on twitter provided a clue "Who kills 80 Teenagers, one by one?" .

We now know there have been at least 94 teenagers murdered, but there are still some young people unaccounted for and still to find. I can only hope they are alive, but the prospects are grim. 

The car bomb was placed near the offices of the socialist government and the teenagers were worker's party members. Rick Falkvinge, the blogger, suggested that the bomb in Oslo itself was a diversionary tactic to keep the police busy while the killer "executed (the teenage party members) in cold blood, as a political strategy to cripple a political party decades in the future." 

The killer's murderous rampage drew the following comment on Falkvinge's blogpost. 

Let Norway show him mercy, not because he deserves it, but because their vision of civilization is more complete than his.

A steady stream of information was tweeted by Ketil B Stensrud, who described  himself as a 'football-fantatic journalist, who worked for The Independent, Daily Mirror, AP, TV2 and VG, turned general manager at Radio NRJ Kristiansand.  One of his tweets contained the following:

BREAKING: Here you can download the Oslo/Utøya gunman's manifesto, in which he gives detailed account of planned attack. 

The manifesto is enlightening, if depressing. 


There are pages and pages of anti-Muslim, anti-multiculturalism rhetoric. There is anti feminist rhetoric. The manifesto is worth looking at as it shows how a mind seeks the evidence it needs to support its biases and bigotry. We are all capable of that self affirming and self referencing behaviour. As you read it, you can see how delusions can become very powerful and how the brain can become closed to any other way of thinking. 

In the document, the killer's reasoning is carefully laid out. His plan to decimate the pro-multicultural element in his country has been brewing for 9 years according to the information in this document. The level of lies and deceit he employed are breathtaking. 


The New York Times article this morning "Scouring the Web for Clues to a Suspected Attacker's Motives" contains sources and links to information about the murderer and his motives by both the journalist and the readers.  A psychologist has, in response to the massacre, written that mass murderers see themselves as victims. That somewhat fits this killer's positioning, however, he seems himself more like an avenging angel or knight. 


He saw himself as a Justiciar Knight fighting multiculturalism. You can read in his manifesto what that means. He surrendered easily to the police when they arrived on the island and under interrogation, confessed to the crimes. This newspaper heading indicates what is to come.    Norway massacre suspect calls his deeds atrocious, but necessary

There have been examples of extraordinary heroism throughout this horrific event by individuals and immense courage and resiliency of the young people.  The leader of the party Jens Stoltenberg has been an inspirational and compassionate leader, saying: 

Today,we have been hit by two savage and cowardly attacks. Tonight, we all stand together, taking care of each other"affirming that "The answer to violence, is even more democracy. Even more humanity"

The massacre in Norway illustrates the profound problems inherent in fundamentalism of all stripes. The killer espouses a vile fundamentalism that strips away people's dignity and worth. His fundamentalism seeks to validate violence for the 'right' reasons of his own making. Norway and her people and their response to this ghastly event remind us that respect for different viewpoints and valuing diversity is the only way humanity can evolve and even survive.  

I feel sad. I feel a bit despairing that a native of a country with such great values and social justice practices as Norway could commit such a crime, but people are people. 


I take comfort in the knowledge that for every person like this dangerously misguided and deluded individual there are thousands who are trying to live life in the best, most socially responsible, inclusive, generous hearted way.  


Elizabeth of @mymilkspilt fame posted this earlier today. The comment summed it all up for me:

 "Compassion hurts. When you feel connected to everything, you also feel responsible for everything. And you cannot turn away. Your destiny is bound with the destinies of others. You must either learn to carry the Universe or be crushed by it. You must grow strong enough to love the world, yet empty enough to sit down at the same table with its worst horrors."

Andrew Boy (Source: myspiltmilk via changingmyperspective, via guerrillamamamedicine)

I don't know who Andrew Boy is, but I sure admire his sentiment.


The following are the last two tweets from the man who provided much of the information I've shared in this blog post. 

ketilbstensrud Ketil B. Stensrud

The brutal, calculated home-grown terrorist has confessed. Rest is now left to our judicial system. I'm exhausted. Time for bed.

ketilbstensrud Ketil B. Stensrud 

One last thought: It's a beautiful world we live in, with warm, inspiring, loving, courageous people all over. Let's keep it that way. Out.

I love his parting comment. It truly exemplifies the spirit of the Norwegian people. I hope he managed to get some sleep.  Thinking of all the people in Norway as they recover and heal from this terrible ordeal and come to terms with the loss of so many beautiful young people. I know that Norway will continue to provide the inspiration, ideals and values that we all love and admire so much; the leadership and people have demonstrated that commitment in the worst of times. 

"All women have the right to dignified health care."

I'm posting this email in its entirety. There is nothing that I can add to the information in this heartfelt request. The title of the post says it all. I've donated and I hope you do too. Thank goodness for women who care like Adina and midwives like Hannah. What a blessing to the world they are!! 


Hello Carolyn,

I read your natural birth blog, and really appreciate what you stand for. I live in a developing country,  Guatemala, where women are not educated about birth choices and many times they only have one option. Due to lack of money they go to the public hospitals where there is more than 70% C-section rate. Then, confronted with birth trauma, they search for any other option possible. Many of them find my midwife with Manos Abiertas, a clinic dedicated to helping these women have a natural birth.

 In a developed country, people have the luxury of forming a self-educated opinion on their preferred manner of giving birth, thankfully, and we are working towards making that an option in Guatemala.

 The clinic that helps mostly indigenous and low income Guatemalan women works on a sliding pay scale. This often means patients visit free of charge or pay much less than their visit costs, because most can't afford the $5 for a checkup. However, as anyone involved in midwifery knows, there are always numerous costs involved.

I am asking you to help by spreading the word via an interview with one of the only licensed midwives in Guatemala who has her own birth clinic: Hannah Freiwald. She explains the situation here: http://www.all-about-guatemala.com/registered-midwife-guatemala-interview.html

You could also help by spreading the news via blog story told here: http://sagaunscripted.blogspot.com/2011/06/birthing-options-in-guatemala-city.html

If you are able to make donations, thank you. If you are not, but you can spread their story, thank you! Every little bit helps.

If you can link to us on your blog or forum, more people will see and hopefully help. I am not a midwife. I am only a citizen who supports my midwife and who sees a very great need with the women of Guatemala. If nothing else, they need the power to choose their birth. They need the right and education to know and choose what happens with their own bodies. Together, we can make this an option.

Thank you,

Adina Barnett

Manos Abiertas

"All women have the right to dignified health care."

Knowing about birth and interventions: Women's role

A recent study by Klein et al, sought to discover the knowledge and attitudes of women pregnant for the first time to their own roles in their pregnancy and towards the use of technology in birth. The report was written up in the Los Angeles times as Pregnant women show an amazing lack of knowledge about childbirth options, study shows - latimes.com . You could be forgiven for thinking that modern childbearing women were obviously failing in their duty to be informed and either submissive or unintelligent.

So who were these women that Klein et al studied?

The sample of 1318 women was a convenience broad based sample of "mainly well-educated, middle-class women" whose planned place of birth

"ranged from home to hospital, and from rural centres to large city hospitals ... 13.2% of respondents were in the first trimester, 39.8% were in the second trimester, and 47.0% in the third"

A good range of sites for birth, so who was their primary care giver?

"Overall, 42.6% were under the care of an obstetrician, 29.3% a family physician, and 28.1% a registered midwife; 18% planned to engage a doula."

OK, nearly half had a private obstetrician, plus nearly 30% who had family physicians makes nearly 3/4 of the total number of women 'under' the care of a medical practitioner.

Now here is something very interesting in this study:

"Women attending obstetricians reported attitudes more favourable to the use of birth technology and less supportive of women’s roles in their own delivery, regardless of the trimester in which the survey was completed"

What do you suppose could be going on there? There is no doubt that some women access medical care because they want the assurance of the ready availability of intervention if they 'need it'. Some choose to have intervention from the start, but that number is considerably less than is touted by mainstream media or medical rhetoric. Part of that orientation however, comes from the steady undermining that goes on at every antenatal visit with many of our medical colleagues. Comments such as 'small pelvis', 'large baby', 'getting stuck', 'bleeding to death', plus the steady supply of 'horror stories' and hype about birth danger that women are regaled with by the doctors as they seek to validate their interventionist perspective are ubiquitous. The orientation that 'doctor knows best' is also very much alive in our community and the way that antenatal care is organised so that the women wait for hours and get seen for minutes feeds the belief system that doctors are 'so busy' and 'don't have time for women's petty concerns' - so women don't raise them in visits - that silence from the women aided and abetted by the 'not wanting to be a bother' stereotypical stance of many women.

Another lens on this phenomenon is provided by this study from 1995 which reported that privately insured pregnant women were more likely to experience interventions and surgical birth than comparable women in the public hospital system, but that the rate of intervention was greater for those women:

"who in late pregnancy were thinking clearly, had high self esteem, mature means of dealing with anxiety, were confident in their knowledge of childbirth procedures and in secure relationships with highly educated men"

A paper in 2000 by Roberts, Tracy and Tracy explored the differences in intervention between public and private hospitals maternity services offers some insights for the higher level of intervention for women in private medical care. Litigation fears, physician convenience factors and theatre staff availability are suggested as reasons for the increased rate of interventions and surgical birth in private hospitals. But what if there is something more 'underbelly' about the way intelligent, articulate women with supportive, educated husbands are subjected to increased rates of intervention? What if it is a situation of putting uppity self assured women in their place? Women will always preference their baby's well-being over their own, so it is easy to undermine them and when they are told that the 'fluid around the baby' is 'suspect' therefore induction is a good idea "I'll book you in for tomorrow" or "you have a placenta praevia (actually low lying) and I'll take the baby at 37 weeks because we don't want the placenta ripping and the baby being short of oxygen" how many women are going to challenge that? So many of the women who are induced for spurious reasons are told after 8 hours of desultory but painful contractions that they aren't going anywhere and may as well have the baby now rather than later when they are even more tired and the baby gets stuck  " I can just take you upstairs/downstairs/across the hall and it will be all over and you'll have your baby in your arms" - who is going to argue then? Anyone who has worked or is working at a private maternity unit can relate similar stories.

This comment is interesting:

"Women attending midwives reported attitudes less favourable to the use of technology at delivery and more supportive of women’s roles"

The fact that these women have a better understanding of women's roles in childbirth is heartening and affirming, as midwifery care is all about capacity building and information sharing. The fact that women who access midwives as primary care givers are less interested in technology comes as no surprise as that is usually one of the reasons women seek out midwifery care. Another important point is that midwives use stories too. Midwives use stories to inspire and instill confidence in a woman's sense of self and ability to birth and parent well. 

The finding that women attending family practices had opinions that "fell between the other two groups" is encouraging, but could clearly be better:

Now, this final finding that:

"For eight of the questions, “I don’t know” (IDK) responses exceeded 15%. These IDK responses were most frequent for questions regarding risks and benefits of epidural analgesia, Caesarean section, and episiotomy".

is very concerning. There is some comfort in the fact that:

"Women in the care of midwives consistently used IDK options less frequently than those cared for by physicians".

as that demonstrates that midwives role in information sharing and discussion about labour and birth is clearly occurring, even though there is scope for improvement. One of the benefits of midwifery care is the longer time for antenatal visits, where thoughts, feelings, stories and information can be shared and discussed. Perhaps the room for improvement here is with models of midwifery care that have short antenatal visit times scheduled and discussions are limited.

The conclusion of the Klein et al study that"

"women held different views across a range of childbirth issues, suggesting that the three groups of providers were caring for different populations with different attitudes and expectations"

is true in many regards, but not in all cases and not for all women. I've met many women who were privately insured and cared for by obstetricians, who were genuinely bemused and upset that they had unplanned intervention, I've seen others who argued that the doctor saved their lives (or the baby's) having (in my view based on observation and experience) created the problem in the first place.

Most people aren't that interested in finding out about pregnancy and birth until it becomes an immediate reality. School, parents and friends provide a particular perspective and background to people's information and knowledge about birth and babies, the media certainly provides another. Many women and their partners have never held a newborn baby until they hold their own. The primary care provider, be it midwife, family physician or obstetrician has a duty of care to provide opportunities to explore information, knowledge, understandings and experiences with pregnant women/couples who access their services.

To say that women are ignorant of options and interventions says volumes about their health care provider. What do you think? 

Healing from Birth Trauma

A very important post on birth trauma was posted by a guest blogger on the wonderful Rachel Reed's  Midwife Thinking blog the other day.  As I read the post and then the comments, I was taken by a young woman's story of her two births; one traumatic and one healing.  I emailed Amber and asked her if she would allow me to publish her stories on my blog because there are many powerful lessons to be learned from her experiences. Amber kindly agreed and here are her stories.  The posts are long, but well worth reading in depth to gather and savour the illuminations she gives us. For those of us who are pregnant parents and those of us who are midwives or other health care practitioners working with birthing women, her words are precious invitations into the world of birth and what women need.

The headings provide links to Amber's blog.

Tale of Two Birth Stories, Part 1

I wish to share my birth stories because becoming a mother is where this journey began. I cannot tell the one without the other—it would only be telling half the story of how I came to be the woman I am today. The birth of my son, now almost three years ago, is still very fresh and vivid in my mind…and deeply painful. I have been repeatedly reminded that I am so fortunate, a hemorrhage is such a little thing; and indeed, as I commented recently, “on paper” it looks like a wonderfully successful natural birth, but to me, it was a nightmare, and one I’ve lived repeatedly over the years. It was only recently that I realized I have truly been grieving over this birth and, allowing myself to go through that process, I believe I have finally arrived at a peace and even a gratitude for that day: for without it I would never had had the courage to take my first step into this wonderful adventure God is unfolding before me now.

I made the choice to birth in hospital as a compromise. I had wanted a homebirth from the time that I knew they were still an option—I’m an introvert and deeply sensitive when it comes to privacy—but due to fear of confrontation and concern for my mother (who is not well and unable to handle stress), I convinced myself that a CNM in hospital wouldn’t be horrible: I still had a midwife and my mom wouldn’t have to worry unduly. I had also convinced myself that Mom had to be a part of the birth of her first grandchild (how could I deny her that?) even though I knew she’s never been able to handle any situation in which I’ve been ill or in pain.

My heart screamed it was a mistake throughout all my prenatal care, but I stuck to my choice even though I was becoming increasingly unwell. Because I was perfectly healthy in all the numbers, my concerns were repeatedly ignored and downplayed as mere complaining. I was frustrated, determined, hopeful, and excited all at once. Thus sets the stage for that eventful day…

Symbols, power and woman's place in the world

I always enjoy Maria Popover's links and articles. Her Blog has fascinating and often obscure articles which are relevant to my interests. I follow Maria on Twitter  - her twitter name is @brainpicker

So it was with great interest that I followed this link

 

to YouTube to see Symmetry, a short vimeo film by Radiolab that Maria said "explores the dualities of human existence, best short film you'll see all week".

 

The film is very clever - it juxaposes images concerning the dualities of existence to explore

"What the origin of the universe has to do with gender identity, binary parallels and anatomy"

I felt disturbed by the juxtaposition of hot chips and tomato sauce, pepsi and coke, popcorn and movies as typical of life on this beautiful planet of ours, but this following image really bothered me

Why does that bother me?

Positioning these images as the gender divide and to represent masculinity and feminity bothers me because of the inclusion of the disabled sign with the woman figure.

Maria says that:

"Symmetry is a mesmerizing split-screen short film exploring the poetic parallels and contrasts of our world — birth and death, heart and brain, masculinity and femininity, all many more of humanity’s fundamental dualities. It’s the best thing you’ll watch all week, we promise"

Given the producers and Maria are cluey in regards to the messages we receive from the visual stimuli around us, it is hard to believe that they didn’t recognise the way this image can subliminally erode women’s sense of self and personal power. Perhaps they didn’t ‘see’ the message the film is sending because that view of women is 'normal' and that makes it all the more fascinating and concerning.

Maria explains that:

"The film was inspired by Radiolab’s Desperately Seeking Symmetry episode, which examines how symmetry and its pursuit shape the core of our existence, from the origins of the universe to what we see when we look in the mirror"

Is that how you see yourself when you look in the mirror?

Here's the film so you can  make up your own mind

Read more: http://www.brainpickings.org/index.php/2011/04/20/radiolab-symmetry/#ixzz1K7q855ff

Symmetry from Everynone on Vimeo.


Those of us who are birth workers are very aware of the way that in western culture at least, women are being progressively disabled to birth normally. Women are embodying the messages that birth is something to be medicated... avoided... that being delivered surgically is preferable and 'safer for the baby' even though it is certainly not.

Our connection to 'nature' is eroding and our birth DNA, our wild side, is getting switched off and put under the lock and key of medicalisation.

The grunting, groaning, sweating, swearing, movement and effort associated with giving birth is increasingly perceived as unbefitting modern women. Birth is now sanitised with pretty delivery room decorations and epidurals on demand. I've noticed many partners and other family members feel relieved when the woman is neatly in bed, unable to move and 'painfree' for labour. The fact that they can't push or move and end up with baby extractions either with abdominal or perineal cuts doesn't seem to be an issue. The disablity accompanying the pain and difficulty moving for some time after the baby extraction doesn't seem a problem for anyone either. '

We have to ask what it is about the birth process that causes all this angst about 'pain' in labour. That's probably a topic for another time.

Back to the images in this short film and what they represent.  My perception is that the unconscious coupling of a woman with the disabled sign positioned as symmetrical with the male symbol is a striking indicator of how women are culturally constructed as disabled in our world. 

The fact that the message is subliminal and that neither the producers, nor those who understand subliminal marketing and neuroscience recognised the message makes it even more powerful and dangerous to women's sense of self, power and place in the world.

And then there is the message about what it means to be female in western society fostered by the likes of  the ubiquitous Child Beauty Pageants.  As  Heidi Davoren, in her column Dirty Laundry for Life & Style section of the Brisbane Times wrote:

"Shame on us as a society that our daughters are groomed into submission, objectification and sexualisation at such a tender age, in the name of entertainment. In fact, in the name of ‘building self-esteem’."

The rampant sexualisation of girls is another powerful and dangerous threat to women's sense of self, power and place in the world.

Raising birthing consciousness: moving beyond cruelty to women and babies

I met a friend for breakfast this morning at a lovely little cafe on the shores of a local lake.  My friend is a Calmbirth practitioner and I have had 30 years in private midwifery practice. We are both passionate about sharing information and exploring ideas about birth and parenting with couples.  Our conversation involved a lot of animated discussion on the subjects dear to our hearts, including why women chose the care they do.

How women and their partners think about the birth of their babies and choose their care provider and their birth place is intriguing.  Women who sought out my midwifery care wanted to know who was going to be with them during their labour and birth, so building trust and understanding during pregnancy was an integral part of their plan. They wanted to ensure privacy and be in control of what happened to them and their baby.  They wanted continuity of care into the postnatal period for support. How their baby was born was something they considered deeply; they wanted their babies to be born gently, into a loving environment and for themselves to be as involved as possible.  These parents desired to be the first to touch their babies; they sought minimal intervention and to discover the sex of their children themselves.  They were fully aware that their baby was a conscious being who participated fully in the labour and birth experience.

According to my friend,  women who access her services don't realise there is any other choice but private or public medical care. They didn't consider public maternity care and didn't generally know about midwifery models of care. As they are generally privately insured, they want to "get their monies worth" by employing an obstetrician and having a private room in the hospital.  We discussed the way that employing a surgeon usually means you will end up with interventions and surgery.


I told my friend about a video on birth trauma that Gloria Lemay had shared on Facebook (see below) and a post Birth Abuse by Navel Gazing midwife.  Routine obstetric management of birth is shown in the video. The video is a compilation of clips are from women's own birth videos collected by a chiropractor and made into this short film. For those not habituated to medical care at birth, these scenes may be distressing, so please take care of yourself when watching this information.
 
Warning: If you are pregnant, it may be best to give this video a miss as you are better off watching beautiful birth films that inspire and support your birth vision.



Birth Trauma from Centre Quiropràctic Molins on Vimeo.


Both those items and the accompanying comments have really troubled me. That women still emerge from their birthing experiences feeling like they have been abused is a dreadful and indefensible underbelly of maternity care. I left the public system thirty years ago to go into private midwifery practice because of the abuse I'd observed. I've written about that in my master's dissertation.
 
My friend told me she had been very roughly examined vaginally during the birth of her first baby and how devasted she had felt after that experience.  She told me that she felt it was the beginning of her slide into severe postnatal depression with that child and the source of the tremendous fear that she felt with her second pregnancy.  My friend said that she didn't stand up for herself at the time and as she was a midwife she 'should have'.  Then she said something that really illuminated the whole issue of birth trauma and abuse for me. She said "I should have stood up for myself, but I didn't have the words to do it..."
 
I thought about the way that women trust their health care practitioner to do the right thing by them and believe their practitioner has their best interests at heart.  Obviously, when the practitioner is rough, or behaves differently to what the woman expects, the woman goes into a shock-like biobehavioural state and has a cognitive dissonance experience. Cognitive dissonance experiences are usually difficult to put into words at the time.

A comment on Navel Gazing midwife's blog explored the Roots of birth abuse. The comment sheds some light on the reasons why birth abuse occurs.  The big question is how do people (partners, family members, midwives, obstetric nurses, doulas, registrars, paediatricians etc) accept these atrocities committed in the name of obstetric 'care'? Mind you, there is conversation in the various tea rooms across the land that revolves around these issues and I know many doulas lament what they observe in labour wards.

Perhaps in the main, the focus of wanting the baby 'out' and 'alive' means the 'how' and the 'why' pales into insignificance until we 'wake up' to the actual brutality of what is accepted as routine obstetrical management. Until we wake up, we are blind to that reality. Blindness to anything other than that which the person is focused on is called 'inattentional blindness'.  An explanation for inattentional blindness can be found in the latest research on how certain neurons actively suppress visual data streaming into the brain. This research informs us that we are only aware of approximately 1% of what's going on around us.


My friend and I discussed ways to provide information to women and men about birth options and ways to raise consciousness about birth choices and effects. How do we help this generation of parents to understand that abdominal birth and vaginal birth are not equal; that the choices they make for their care will have profound effects on the outcomes and their experiences?  How do we create a culture where violence against women and babies, even that form of violence couched in terms of 'obstetric care' is unacceptable? How do we lay the foundation of kind, respectful woman centred care in maternity services? How women are treated in their most vulnerable state during childbearing provides a template for how society treats women generally. How do we help parents recognise and engage with the spirit and consciousness of the child that is embodying and being born?

Senate Inquiry re: complaints about midwives

The Australian Senate Finance and Public Administration Committees are holding an Inquiry into the administration of health practitioner registration by the Australian Health Practitioner Regulation Agency (AHPRA). On 23 March 2011 the Senate referred the following matter to the Senate Finance and Public Administration Committees for inquiry and report.
Inquiry into the administration of health practitioner registration by the Australian Health Practitioner Regulation Agency (AHPRA). Submissions should be received by 14 April 2011. The reporting date is 13 May 2011.

The Committee is seeking written submissions from interested individuals and organisations preferably in electronic form submitted online or sent by email to fpa.sen@aph.gov.au as an attached Adobe PDF or MS Word format document. The email must include full postal address and contact details.

I have just sent my submission to this inquiry.

The situation as it stands is like this report from Kelly at the Belly Belly site:

"There is currently a major problem occurring with the process of complaints about midwives.

Several midwives around the country have had conditions placed on their registration due to complaints. These complaints are mostly from hospital staff when a labouring woman and her partner are transferring from a homebirth. Most of these restrictions demand that the independent midwife can only practice midwifery within a hospital birthing unit. This brings their homebirth practice to a screaming holt, leaving their women without a care provider and the midwife without an income!

The process as it currently stands is this:

The hospital staff or anyone put in a complaint to the Nursing and Midwifery Board (NMB) about a midwife. The Board meet monthly and decide whether the complaint needs to go to investigation or not. In some cases they’ll decide it doesn’t need an investigation and the conditions will automatically go onto the midwives registration.

If they decide it needs investigating they slap ‘interim conditions’ on the midwives registration. In the case of homebirth midwives the conditions are “Must work only in a hospital and under supervision”.

The investigation then goes to the HCCC and the conditions remain on the midwives registration until the investigation is complete.

Basically, it is a matter of midwives being found guilty until proven innocent.

Investigations can take a year or more. This is leaving many women without a midwife (some are 39 weeks pregnant) and leaving midwives without income – and for some it could be a matter of losing their home, as they cannot pay their mortgage etc".

Given that the Collaborative Arrangements Inquiry had thousands of submissions which the committee dutifully ignored, it will be interesting to see what they do with the submissions for this one.
 
We live in hope that sanity and a 'fair go' for women and midwives will prevail in Australia.

A coroner's perspective on the death of a baby

The coroner, in his report released today on the intrapartum death of a baby girl at a private hospital in Queensland, was critical of both the midwife and the obstetrician involved in the labour and birth care of the mother.

The care was found to be substandard by the coroner on many levels.  The midwife was found to have altered the woman's medical records after the event; did not follow hospital protocols regarding monitoring and documentation and did not refer to an obstetrician in a timely manner. The coroner will be reporting the midwife to the Director for Public Prosecutions.

The coroner found the doctor's response to the clinical situation to be ''inadequate" and recommended that he be reported to the hospital board.  I wonder why the coroner is not reporting the doctor to the Director of Public Prosecutions too?

The coroner made 21 recommendations from the content of antenatal education and the way they are formatted to the essential nature of good collaborative care for safe care of mothers and their babies.

The president of The Royal Australian and New Zealand College of Obstetricians and Gynaecologists (RANZCOG), Dr Rupert Sherwood commented that this case highlighted the reasons why the college "has always insisted on collaborative arrangements between doctors and midwives".  He further claimed that there were two aspects of good collaborative care: adherence to protocols and timely referral. Those aspects, while very important, are not the key to what constitutes either collaboration or safe maternity care.

There is no doubt that collaborative maternity care is the safest for both mothers and babies. I have had the supreme good fortune of working collaboratively with a number of skilled, compassionate and insightful obstetricians. I have sadly, had the misfortune of working with the others too. The key to collaborative maternity care provision is the way the organisation is structured. There are two aspects to that positioning. One, that the organisation overtly recognises that birth is a normal natural event which sometimes needs expert and timely intervention. The other, fundamentally crucial aspect is the acceptance and promotion of the woman's right to self determination, evidenced by the woman being treated as an equal partner in the care planning and giving. A woman centred maternity service, where both obstetrics and midwifery AND the organisation has the woman, her wellbeing, her desires, needs & requirements at the centre of their practice leads to the leveling of hierarchies and the destruction of professional 'silos' which engenders an atmosphere of trust with optimal communication.  I found in my research that without that organisational structure creating the culture of collaboration, with warm, trusting relationships of mutual respect and woman centred practice, both doctors and midwives lose their emotional and social competence, they act stereotypically, the turf war is in full swing and mothers and their babies suffer.

The loss of this little baby Samara is a tragedy for all concerned.  The fact that with good collaborative care, this baby's death could most likely have been avoided is heart wrenchingly tragic.

This coroner's report is a must read for everyone associated with maternity services, from caregivers to managers as it contains important directions and information regarding staffing, culture and practice.

Maternal intelligence: Calling the baby in

I've just read the most intense and illuminating blog post of a woman's birth story.

Rixa, of Stand and Deliver fame, posted the story of her baby Inga's unintended unassisted birth at home. One of my favourite comments, showing Rixa's wonderful presence of mind is when she was seeking to understand how close to birth she was...

"I knelt and reached inside. Sure enough, there was a hard round head about two knuckles deep. I felt around for a while, trying to figure out what was what. With all of the folded tissues and wrinkly baby’s head, it’s sometimes hard to tell where you end and baby begins!"

Baby Inga needed resuscitation, which Rixa did brilliantly.  You can see how Rixa managed the resuscitation of her baby with great mindfulness and focussed attention in the second video on her blog about Inga's birth.

Rixa explained that she had been certified in neonatal resuscitation a few years before. I'm not sure what other midwives do, but for anyone I considered could labour and birth quickly, I made a point of taking them through resuscitation of the newborn in case the baby arrived before I did. These days I recognise everyone needs that information, both for birth and beyond. We never know when those skills may come in handy; a woman told me that she was so glad I'd taught her as she had resuscitated a friend's child who fell in a swimming pool.

In terms of a newborn's transition to extrauterine life, certainly having the cord intact helps. Anyone who has seen a newborn with the cord clamped and cut immediately at birth would recognise the extra effort it takes for those babies to ground themselves and recover from the birth process.

Watching Rixa resuscitate her baby with five quick breaths and words of encouragement is a useful and informative experience for anyone to view. The way she talks to her baby is so important and I encourage mothers and fathers to do the same when they are in labour and when the baby is born.  "Calling the baby in" to its body is an essential part of the birth and transition to extrauterine life process and the importance is an understanding shared by Indigenous cultures and homebirth midwives. "Calling the baby in" is a recognition of the spiritual essence or consciousness of the baby and indicates an understanding of the way that the spirit can separate from the body (also known as 'out of body' experiences) during intensely emotional and/or challenging times. My personal view is that a mindfully aware, welcoming and lovingly focussed on the baby mother (and father) is the most important safety feature of labour and birth.

Rixa's birth and action to help her baby reminded me of the maternal intelligence in this video (following) of an elephant mother.  Some people may be offended by the association of an animal's behaviour with that of a human. However it is important to recognise that scientists use animals in all sorts of  ways to see how they respond to get insights into human experience and behaviour. Therefore it is highly appropriate to think about the commonalities in these two mothers and their attention to the needs of their newborn babies.  We are wiser with the way we treat animals as we realise we have to leave them alone to birth normally. We recognise that surveillance and well meaning intervention does more harm that good with animals. We have yet to fully appreciate that with human labour and birth.

The elephant mother is Nikki, her baby is Riski.  Note the mindful attending presence of the elephant mother and the way she calls her baby in. Watch the baby's eye as the spirit enters and stays.

Whatever your perspective about spirit, consciousness, birth, danger, surveillance, mother's innate intelligence, newborn babies resilience etc, these videos and the maternal intelligence that is evident in these videos invites us to think deeply about these matters.

Birth Genius

Birth is amazing.

Women's embodied wisdom about birth is brilliant and babies ability to be born is stunning. Both geniuses come together when they are supported wisely in an optimal environment to express their innate ability and intelligence. 

Trust, both of self and the others in the birth environment by the woman is a powerful mediator for birth to go well.

The others have to be trustworthy though.

This video gives an excellent example of genius in action.



I would have loved to see the woman hold the baby, the cord to have been left intact and the film to have shown the placenta being born.  I do love seeing this video of the birth of this footling breech baby with the cord around it's neck three times. I've watched it quite a few times!

There is something exquisitely satisfying about an example of everything being right with something that others say is wrong or dangerous. An example of natural intelligence in action.

The gentle way the practitioner held and touched that baby was delightful and reverent, as it is meant to be.

I couldn't help but compare that behaviour of the doctor in the video to the behaviour I saw recently at a birth.

The doctor kept poking and pushing at the baby's head as it was being born.  The doctor then pulled the head around, twisting the neck the wrong way ( I said where the back was on palpation; that information was ignored).  Then, obviously worried about the possibility of shoulder dystocia, the doctor proceeded to tug the baby out.

The woman tore and needed sutures (not as bad as last time apparently!).

I felt strongly that the meddling caused the tearing. She had been labouring in a quiet, self managed way and if she had been supported to push that baby out with her urges, with patience and direction to push gently between contractions, she could have avoided the tear.

I guess surgeons don't have a problem with suturing, after all, it's their bread and butter.

For the woman, however, it's her body and good to keep intact.

I also recognise that the recumbent position leaves women open to being 'manhandled' during birth. An upright position makes touching so much more difficult. I suspect that the vulnerabilty inherent in the recumbent position makes touching and manipulation 'ok' whereas when a woman is upright, she is more in her power. I wonder if her size in an upright position appears bigger and therefore less vulnerable?  Lying down was her choice and of course, should not be an invitation to unnecessary interference.  I wonder if lying down on our back triggers the primitive brain region to assume dominance in those that are upright?

When Tracy Donegan read this post, she sent me an article about positions of power posing and neuroendocrine effects.  Thanks for this information Tracy!

Another beautiful example of breech birth is given by Lisa Barrett on her blog. One of my favourite photos of birth is in the photo essay.

Lots to think about here.

The Secret to Blogging?

I called this blog 'ThinkBirth' because as a midwife, I've thought a lot about birth, women's experiences, babies experiences, men's experiences, midwife and doctor relationships, pregnancy, breastfeeding ... you get the idea

and of course, I can make anything relate to childbearing - nutrition, exercise, brain development, epigenetics etc and of course all these topics do, in one way or another. 

That reality is probably one of the challenges that comes with having a deeply developed holistic viewpoint :-) everything seems relevant. 

There are some fabulous midwifery and birth related blogs out there. Midwife Thinking for example is a well written, incredibly practical, well researched blog.  Some are very scientific and challenge the status quo like Science and Sensibility and some, like Midwife Mutiny have lots of lovely birth stories and share controversial ideas about midwifery.

There are a zillion others. What makes people want to read a blog? What inspires people to comment, to engage in conversation about the subject of the posting?

To find out, I've been paying attention as I read different sites and explore various subject areas. I've been observing what attracts me

(and lots of things do, surprise, surprise!)

There are lots of experts giving advice on what makes a great blog. The most consistent suggestion seems to be to focus on your niche when you write.

Find the area that fascinates you, the area you know most about and blog about that.

That advice gave me a bit of a jolt. I tend to be wide ranging in what I put on this blog. Because I'm a curious person, I find lots of things that interest me. I also love sharing information and ideas, so anything that 'grabs' me, I think you may be interested in too.

But perhaps my approach is wrong. Maybe you would really enjoy or prefer a niche blog. 

What would you like? Stories? ideas? guest bloggers? a focus on a particular area to do with childbearing (the skies the limit there!) for example, preconceptual matters, prenatal matters?

Midwifery students?

Education? 

Take a minute and drop me a note. Let me know what you think/want.  I'd love your feedback. I look forward to your comments.

Carolyn