"I was pathetic"

I struck up a conversation with a mother I'd never met before at Mainly Music this week. We were covering all the usual stuff: do you live around here, how old's your kid, what's his name, got any other kids, etc.

Before long it came out that she was hoping to have another child but worrying that, at the age of 43, she'd left it too late. I asked her if she'd had trouble conceiving her toddler and she said no, they got him first try (which made me wonder what she's worried about, but there you go). Anyway, in amongst discussion about IVF, breastfeeding and natural fertility, as women often do, she hinted at his birth story. She'd had no trouble conceiving, she had a great pregnancy, not such a great delivery, but really, things have gone so well for her overall...

Of course I wasn't going to let that comment slip by so easily. Not such a great delivery, you say? 

No... Well, he was an emergency caesar. All my vitals were dropping. Nothing wrong with him. I was pathetic.

What? What do you mean, pathetic?

Oh you know, I had such a great pregnancy, I was fit and active, I was doing yoga the day before he was born, but when it came to labour... I just couldn't cope.

You weren't pathetic. No woman is pathetic in labour. It's the most incredible experience, it pushes you beyond anything you've ever done before. You're not pathetic.

I didn't actually say that last sentence, but that's exactly what I was thinking. It broke my heart to hear this woman speaking so badly of herself. Ten years older than me, looking younger than 30, easily conceived a child at the age of 40. But in the system, a system that says a woman over 35 is damaged goods no matter how healthy she is, no matter how active she is, no matter how great her pregnancy is. A system which slapped a big fat "high risk" label on her forehead and made it a self-fulfilling prophecy. And she now carries that label with her everywhere, has internalised it so much that she goes around telling random strangers that she was pathetic.

How terribly, terribly sad. I can only hope that self-hatred has not spilled over to other areas of her life.

Dear women of the world, YOU ARE NOT PATHETIC. Please understand this. It is not you who are broken, it is the system that works against you which needs fixing. Please extend yourself the same compassion you would extend to your best friend if she was suffering an emotional wound, and believe that you are better, stronger, braver, more capable and more beautiful than this world would have you think. I wish you peace, love and healing.

24 weeks

All going boringly well, thanks.

Rosie loaned me her fetoscope a few weeks back and we've been having fun using it. I've only been able to hear Tiger Meat's heartbeat a couple of times (cos mostly it just feels like I've plugged my ears with cement), but Craig can usually catch it. He also does our traditional ear-on-belly method of fetal monitoring, and it's always been within the range of normal. Yay.

At 17 weeks I went to a GP to get my ferritin level (i.e. iron stores) checked, cos I was feeling like it must have been really low. While I anticipated a possible conversation about homebirth -- and in some otherworld fantasyland I even hoped she'd be supportive of it -- I was caught off-guard when one of the first things she said to me was "Well, 17 weeks, you'll be needing to book in a ultrasound soon, won't you?" Dang. Sometimes I forget that I'm Different. What ensued was me politely but firmly explaining some of my reasons for objecting to ultrasound (I used all the really lame ones because I couldn't think of the good ones in the heat of the moment; I suck at arguing), and countering the dead-mother card in the event that I was one of those 1 in 500 women with a complete placenta previa and I hadn't noticed it before the commencement of pushing. She didn't even go for the dead baby card! (For the record, complete PP occurs in about 1 in 1000 pregnancies, it is easily diagnosed in late pregnancy and easily misdiagnosed in mid-pregnancy, and I have only one of the five or six risk factors for it.) I will credit the GP with backing down once she realised I knew my stuff, but afterwards she took my blood pressure. 160 over 90, and a pulse rate of 110. I have since learned from Rosie that the figure they use as the baseline measurement for normal blood pressure in pregnancy is whatever BP reading you get at your first antenatal appointment. Um. Haha. So I have to credit the GP with also acknowledging that she was grilling me on my views about homebirth and ultrasound at the time, so at least she didn't try to tell me I was a red flag for pre-eclampsia. Nevertheless, for my own curiosity's sake I'll get my BP read by Rosie next time I see her.


Anyway, several weeks later... I do have this one weird pregnancy complaint, and it's been common to all of them, which is a stuffy left ear. It just randomly pops sometimes. I tried researching this phenomenon when I was pregnant with Cassia (and even went to a GP about it, but all she did was stick one of those poky things down my ear canal and declare nothing unusual), but came up with nada. My suspicion is that no studies have since been carried out, or if they have, some professor-supervisor with a bee in his bonnet is refusing to let his PhD student get their work published, but I can't be bothered googling to confirm. Once baby is out, it'll go away.

I was feeling oddly disconnected from this pregnancy until yesterday, when I finally got photographic evidence of my expanding belly, and now somehow it's real and I'll actually be giving birth again in a few months. Wheee!

Cos arty-farty is always a better way to capture things

The Face of Birth

I recently saw and have purchased this new Australian film, The Face of Birth. It looks at the issues surrounding homebirth as a valid, if marginalised, birthing option in this country, and follows the stories of several homebirthing women interspersed with commentary from various birth experts in Australia and around the world (including Sheila Kitzinger, Ina May Gaskin, Michel Odent and Robbie Floyd Davis).

Ilythia Inspired has written a great review of the film along with a follow-up critique, so there's no need to repeat most of what she said. However, here were a few highlights from my perspective:

Noni Hazelhurst. To put it quite plainly, the woman rocks. Her warmth, humour, down-to-earth presence and insightful commentary on her own homebirth experiences and the state of birth in this country were wonderful. (Everyone in Australia knows who Noni is, right? For anyone else, she's an actress and TV presenter for whom my generation has a special affection because she was on Play School when we were kids.)

Hannah Dahlen, Associate Professor of Midwifery at the University of Western Sydney. WOW, she was powerful in this film. She said so many things which I found myself nodding vigorously to and thinking "YES! Will everyone please just LISTEN to what she is SAYING??!!"

The two traditional midwives serving a remote indigenous community in the Northern Territory, who explained their method of turning breech babies. In 50 years of experience, they have never had a breech birth.

Euan Wallace, Director of Obstetric Services at Southern Health (which serves a very large cohort of Melbourne's population). He was honest enough to admit that "looking after healthy pregnancies [in Australia] is the bread and butter for a large section of the obstetric workforce. It's very difficult to relinquish that, it's not something you can give up overnight, it's a massive industrial change. That doesn't exist in the UK under the National Health Service where obstetricians actually want to look after complex pregnancies and complicated births only and are very happy to leave the normal healthy pregnancies to midwives or GPs, and I think that's healthy and if we were honest, if we stood back from it, that's probably in the interests of women."

Kate Gorman, one of the film's writers and producers. Her story really struck a chord with me, especially the way she described her final meeting with her private obstetrician at 36 weeks with her first baby, which made it clear to her that private obstetric care wasn't what she wanted or needed.

Having said all that, the film is not without its issues. There was a huge emphasis on homebirth as safe only for "low risk" women, without a strong definition of what "low risk" means and who determines it, and a pathologising of variations of normal (post 42 weeks, low amniotic fluid, cervical lips, stalled labour, older mothers, etc) which served to reinforce the notion that pregnancy and birth are inherently problematic and something to be nervous about. Midwives were still portrayed primarily as medical professionals there to look out for the mother and baby's safety, and secondarily as emotional support people holding the woman's birth space. I thought that one of the women telling her story probably needed to do a lot more debriefing of her homebirth after caesarean (although thankfully the film didn't pathologise VBAC!), and another probably ended up with an unnecessary transfer to hospital and subsequent caesarean. It would also have been good to hear more from some Australian midwives in private practice.

There's another Australian documentary in the pipeline entitled Trusting Birth which may address some of these issues, however the film's producers (two homebirthing mums) need a little financial assistance to make it a reality.

My white privilege

Nearly 18 months ago I found myself in conversation about birth with a woman who had a boy about the same age as Elliott. At the time she was telling me how she'd had caesareans for both of her births (she had older twin girls as well) but would have much rathered not, and expressed her belief to me that I was lucky for having had "natural" births. I had hoped to be able to follow up with her in future, and indeed I did get that opportunity, but I never blogged about it because it was too harrowing and personal a topic to get into. In summary, she was an immigrant who'd had her girls at the age of 16 in the hospital here after having just arrived from Afghanistan (she said they lied about her age and said she was 18 to get her into the country; her husband was in his 30s). She struggled with caring for the twins under her circumstances and they were taken away from her and put in foster care for a year. She had visiting rights with them, but the pain in her heart was obvious as she struggled to tell me her story without crying. Further to that, they sterilised her with Depo-Povera without her informed consent. Four years later she had her son, and while now I can't remember the details of how that all took place, I do remember that she was afraid the authorities would find out she'd had him and would take him away as well.

I only ever saw or spoke to her once again after that conversation, and it was a brief hello as we passed each other at the local shopping centre. I had wanted to reach out and help her somehow, even got her phone number and offered to come over one day for a coffee and chat, but she seemed embarrassed by how much she had already told me of her story and I suspect she was afraid I couldn't be trusted not to dob her in to anyone. These days I think she probably gave me a false number, as I never did get hold of her when I tried to call.

I felt overwhelmed by the pain and distress of her situation, as well as the sheer helplessness of not being able to solve her problems for her. I was so angry at what they had done to her, starting with that first caesarean which I will bet any money she didn't need and greatly exacerbated her difficulties in those early weeks and months of parenting. I was also shocked at the glimpse I was getting in the window of my white privilege; something I had only ever considered as a social theory that had no real relevance to my life. Now I was talking to a flesh and blood human being whose life story showed that that sort of discrimination and lack of true support for underprivileged people really does exist. In my own neighbour's back yard.

Over a year later, I have just completed a summary task for one of my CBE course units called Values and Diversity. It's looking at the issues of dealing with people of different cultures, with different values and ethics, and how such issues may affect my practice. The task was to choose a minority group in my local area that I am not a part of, and find out more about the specific challenges they face and how I might work with a client from that group. I chose to research Sudanese immigrants.

It was eye-opening and somewhat depressing to realise just how little support these people (as well as migrants from any other country, particularly non-English speaking ones) have in this community. There is not even a general migrant resource centre in the local area -- the closest one is located in Dandenong which is not part of our local council. (There is a small community development agency dedicated to humanitarian efforts in the Sudan itself which also provides some support for Sudanese migrants in the local area.) What I did find thanks to Google was plenty of links to forum posts written by people complaining about what bad drivers migrants are, how violent, alcoholic and disease-ridden they are, how "every Sudanese woman [they] see is pregnant just so she can get the baby bonus", why Ms Gillard should send them all back to their own countries and so forth. I also found at least three links to a news story from 2009 in which racist leaflets had been distributed around Frankston scaremongering people into believing that Sudanese refugees were likely to rape or commit other violent crimes against them, and other such sensational accusations.

I tried to imagine what it must be like for a Sudanese woman giving birth in Australia. I have heard that they tend to be very afraid of doctors (and one more official document I found online acknowledged that amongst the social challenges Sudanese refugees face, distrust of authority figures is one of them, most likely thanks to the corruption that exists in their homeland), and because so many of them lack proficiency in English they tend to be left alone when in hospital anyway. That's actually probably a good thing, unless they're experiencing a genuine medical complication in birth... It occurred to me that of all women, these ones would benefit most from a doula, except that how many doulas would be up for the challenge of assisting a woman who doesn't speak much English? And as I took the time to really stop and contemplate life in the shoes of someone else, I once again saw my white privilege in all its glory.

Of course, I'm not ashamed to be who I am. But I have had a sobering reminder of how easily I could be Someone Else, how difficult life is for them, how useless it is to complain about Their Problems without any understanding of why Their Problems exist (or any sense of responsibility to find out), how damaging it is to remain in prejudiced and fearful ignorance of reality, and how hopeless the situation is without God's direct intervention in the affairs of human beings. Once again, I'm praying Your Kingdom come.

Perspective and Recognition

I've just completed a really interesting unit in the Teaching Skills module of my CBE course. It was called Perspective and Recognition, and dealt with recognising the perspectives of our clients and how those perspectives affect their choices, goals and chances of reaching those goals. It built on an earlier unit from the Communication module about active listening skills, and was designed to enable us to focus on what our clients need, rather than what we are eager to offer. The point is to help us support our clients by effectively meeting their needs and also to avoid the burnout and frustration that so many birthworkers face, especially when they see their clients make choices which lead to interventions they said they didn't want.

Challenge alert. I've already had to question myself several times as to why I really want to become a childbirth educator, and I've had to let go of my need to save women from the system. It helps to take myself back to where I was at before Cassia was born, and remember why I made the choices I did -- and to consider what one particular friend must have been thinking as she watched me get on board the train and then try to extract myself from the rubble of the wreck it led to. It also helps me to remember that it all happened the way it had to happen; that that was the path God led me down for my benefit, and without that journey I would not be where I am now. But still, I don't find this business of separating myself from other people's experiences easy.

Anyway. The unit provided a hierarchy model, based on Maslow's Hierarchy of Needs, to explain the various attitudes and perspectives women may bring to their birth experience, and I found this a really useful way of understanding how best to help them. At the most basic level you have women whose only goal is the safety of their babies and themselves, who are happy to entrust all decisions to their carers and are least likely to be interested in exploring their options. They carry the belief that "whatever will be, will be" in birth, and their job is to simply get on with it. Birthworkers can help by providing reassurance and supplementary advice to whatever their caregivers have already told them.

At the next level are women who are looking for support from peers. These women will probably join a childbirth class, but their interest is not so much in gaining information about birth as it is in joining a group of women going through the same experience as themselves. They are most comfortable conforming with their peers in their birth choices, and are unlikely to challenge their caregivers about any aspect of their care. In fact, being presented with alternative choices is likely to be overwhelming and lead to a feeling of being out of control. Birthworkers can help women on this level by providing education that answers their basic questions about birth, and opportunities to network with like-minded women.

On the third level  are women who realise that there are many different choices available and that they have the ability to seek out a carer who will meet their needs. They are likely to be interested in writing a birth plan that takes into account their particular needs and preferences, however, they are still unlikely to be comfortable with making choices that will lead to conflict with their caregivers. These women can be a little more difficult for birthworkers to help in that it often comes down to how much information they really want (and this is not usually obvious); too many options are likely to overwhelm them, especially options which would mean going against their careprovider's advice. However, birthworkers can be very helpful in assisting them to formulate birth plans that are realistic and achievable according to their expectations.

Next are women who have identified the type of birth experience they want and are determined to achieve it, but either are still unsure of the steps needed to get there, or know the steps logically but are reluctant to take them due to the challenges this may create. They are willing to question their caregivers and negotiate on issues that are important to them, but are unlikely to go directly against their caregivers' advice. At this level birthworkers are most effective if they provide guidance which will help such women explore their choice of caregiver and reach answers to their questions themselves.

On the final level are women who are very clear about the type of experience they want and are willing to take full responsibility for the outcomes of their choices. They are prepared to take whatever steps are necessary to achieve their goals, including changing caregivers. They see their partners as part of the decision-making team but themselves as the ones birthing their babies, and therefore they make the final decisions. These women may look to a birthworker for evidence-based information that will help them make their decisions, and for inspiration from other women who have had the kind of birth experiences they want and/or a firm belief in their ability to achieve the same.

The unit also talked about how women on the different levels of this hierarchy will process their birth experiences. I found this really fascinating too. On the first level, a woman is most likely to accept the birth for whatever it was, and not question whether any interventions that may have occurred were necessary. On the second level, she will feel a close affinity to other women who've had similar birth experiences to herself, and will have difficulty comprehending mothers who feel differently about theirs. She is unlikely to question whether anything could have been different, and will not see how her own choices and actions may have had any bearing on the outcome. At the third level, a woman will feel happy with her experiences and decisions as long as everyone who supported her is in agreement about them. If she had a doula who suggested alternatives, she will feel torn between seeking approval from her and seeking approval from her doctor or other careprovider. If she had a positive experience she will feel it was because she planned her birth well and had a caregiver who supported her. At the fourth level a woman will feel a strong sense of disappointment or loss if she did not have the birth experience she was hoping for. She will spend time processing her experience, looking for explanations and seeking meaning in it, and will spend considerable time working through the choices she made and whether there were alternatives she didn't explore. (Uhh... hello!) Finally, a woman on the fifth level will feel a sense of acceptance whatever the outcome of the birth, and will feel strongly that she made the right choices for herself. She will feel a compelling need to talk it through with many people, sometimes for months afterwards. (Haha! You've been warned, peeps!)

The unit also made the point that birth experiences are sometimes the catalyst to spur women to reflect on their choices and perhaps move to a different level of the hierarchy, but that it's not the birthworker's job to make a woman do this. She can only do it for herself, when she is ready -- and it may never actually happen. I've struggled in the past to come to terms with this too. At what point am I just opening a door to women, and at what point am I trying to push them through it? A lot of women don't even want the door opened, and will interpret it as being pushed. Well, that's a whooooooole 'nuther aspect of my personal journey through all of this stuff, and I'll save it for some other time.

Book review: Birth Matters: A midwife's manifesta

As its subtitle suggests, Birth Matters: a midwife's manifesta by Ina May Gaskin is addressed primarily to midwives, and by extension all birthworkers, including obstetricians. It is an urgent call to regain trust in women's bodies to handle the natural process of birth, return the ancient art of midwifery to its rightful place at the centre of childbearing women's lives, and make crucial changes to the current system of maternity care in the USA.

Gaskin casts a critical eye over this system, highlighting the fact that a woman who gives birth in the US today is twice as likely to die as her mother was. The US ranks behind 33 other nations in neonatal mortality rates, and 40 other nations in maternal mortality rates. These, the gross under-reporting of maternal deaths related to childbirth, and the rapidly increasing caesarean rate (currently one in three births nationwide) are all occurring despite the fact that the US spends more money on maternity health care per capita than any other country in the world. Clearly, something is amiss.

Ina May takes us through the history of midwifery and obstetrics in the USA, showing how the former was swiftly and systematically wiped out by the latter during the first half of the 20th century. In more modern times, insurance companies have weighed in, dictating policies which prevent doctors from facilitating births that once would have been considered normal (e.g. breech) and consequently causing the loss of vital obstetric and midwifery skills. Gaskin also takes issue with second wave feminism's failure to recognise birth, motherhood and midwifery as crucial means of female empowerment, and thus inability to fulfill its potential to be the strongest, most vocal advocate of birth, and indeed all women's health reform.

Her chapter entitled My Vision for the Future outlines the vital steps Ina May believes must be undertaken to improve the system -- these include having woman-centred maternity care in which midwives are the primary carers for pregnant women (this is especially relevant to the US, where midwives make up only a small percentage of the total number of carers available; the majority of staff working in hospitals are maternity nurses with little training in midwifery), a revision of medical training so that physicians first learn about (and witness) normal birth before moving onto abnormal birth, the establishment of the Mother-Friendly Childbirth Initiative as the gold standard of maternity care, more free-standing birth centres, a nationwide overhaul and standardisation of the maternal death reporting system, and post-partum home visits to be included as part of the standard care given to all birthing women.

Although she is openly critical of the current maternity system, it's important to note that Gaskin does not seek to inflame any of the debates around pregnancy, birth and motherhood which polarise people, particularly the doctor vs midwife or homebirth vs hospital birth debates. That is not her point; her point is that the system is broken and needs urgent fixing, especially in the matter of maternal deaths. This is probably best summed up in her concluding paragraph:

It is time to stop the witch hunt and save both midwifery and obstetrics by educating women, future midwives, and future doctors in the wisdom of nature's design for birth. All the women and men -- midwives, nurses, obstetricians, and doulas - who preserve the midwifery model of care, and honour the medical oath to first do no harm, deserve our admiration and our support should they come under siege. Part of our work in reinvigorating the women's health movement must include creating communities and support networks, so that caretakers are enabled to do the right thing.

I found this book to be a powerful analysis of the biggest issues in maternity care throughout the world, as even though the focus was on the American system, most of the same problems exist elsewhere (particularly in Australia, where "midwives" are most often relegated to the role of obstetric/maternity nurses and do not enjoy freedom of professional autonomy unless they are in private practice). Ina May's tireless efforts to bring these issues to our attention, along with the historical and cultural contexts in which they exist, must be respected and valued if we truly want to see the reforms she advocates. Birth Matters has been written in her usual challenging but inspiring way, and I would love to see this book become required reading for any aspiring students of midwifery or obstetrics.

Book Review: The Vaccine Book

There is a fairly large selection of books on CBI's approved-for-book-review reading list which are related more to issues of early parenting than to pregnancy, birth or breastfeeding. One such book is Robert Sears' The Vaccine Book, which I took an interest in from a personal point of view as well as because I'm sick to death of reading about birth at the moment (yep, it can happen; you read it here! *wink*).

It's an excellent read; the most informative, balanced, honest, and non-emotive thing I've ever come across about vaccines. Sears' own bias (i.e. pro-vaccine), which he is completely up-front about, does not interfere with his ability to provide an impartial analysis of vaccination issues, nor his ability to remain completely respectful of parents who choose to delay, only partially vaccinate, or forego vaccination altogether. The only really big sticking point I have with it, and this is hardly Sears' fault, is that it's written almost exclusively for an American audience (there's a chapter dedicated to the Canadian vaccine schedule, but that's it). Consequently, it's of limited value to Australian parents in that there will inevitably be differences between the two countries in terms of which brands of vaccines are available, and the incidence and risks associated with the diseases they prevent. However, my belief is that the differences are probably not significant. I know that the Australian Vaccination Network provides information about the brands available in Australia, although I am a little leery of that site because it's emotively anti-vax and not all the links within it work.

I would have liked to see a more thorough analysis of the anti-vaccination movement's concerns about the long-term consequences of vaccination (in particular their effect on gut health, allergies and intolerances), however, Sears admits that there has not been solid research into this issue so there isn't really much to say. I did appreciate his perspective on the common argument that vaccine-preventable diseases were already on the decline before vaccination was introduced -- which is to say that yes, they were on a slow decline but there is no question that vaccines have been the main cause of their more sudden decline in recent years. I also appreciated his frequent acknowledgment of the role that breastfeeding (and avoiding day care) plays in minimising children's risk of catching these diseases, and he recommends that children be breastfed for at least a year, preferably two.

As a childbirth educator I expect this topic to come up with clients frequently even though it's not my field of expertise, so I am glad to be able to have an excellent resource to point parents towards as they journey through the vaccination minefield.