This elderly midwife buried the placenta outside the hut or dropped it in water, and advised the mother to drink taro and cassava, either boiled or as juices, and eat vegetables and fish. She gave the mother herbs when a newborn baby was not thriving, the essence of which would be conveyed to her baby in the breastmilk. She told me that sex while a woman was lactating ‘spoils the breastmilk’.
Sweden
Janette Brandt, a bright spark in the Swedish birth movement, came from Abergavenny and first met me at the NCT in London, in 1962, when I gave a talk on breast feeding. She writes in a series of emails to me in 2014: ‘There you were, up front, with breast milk oozing through your bra, leaving damp patches on your bust and so rapturously happy that women can nurture their babies without having to rely on the bottle!’
‘When I arrived birth preparation was stagnant! Dick-Read’s method had been adopted – but not modified over 20 years.’ Janette started groups in Adult Education Schools (AES), but a year later the Government reduced financial support to all AES.
‘Psychoprophylaxsis was introduced in Sweden in 1969 and presented as “Learn to Give Birth”! Defined levels of breathing had to be … used systematically, all with the purpose of blocking pain sensations. Another issue was that there were too few anaesthetists to provide adequate pain relief when necessary. This situation gave rise to pressure groups. Some wanted the right to “pain-free birth” using epidurals. Others … claimed the right to give birth with little if any pain relief medication, using PPM (Psychoprophylactic Method).’
‘In 1970, Sheila Ljungren (an English NCT Member in Gothenberg) and I publicised the need for a Swedish counterpart to the NCT. We contacted Bonniers, and in 1977 your ‘Experience of Childbirth’ was translated and published as ‘Aktiv Forlossning’ (Active Birth).’
‘Comments have been made to me over the years that I must have had a tough time dealing with all the back-biting talk that was directed at me, but in all honesty it didn’t have the impact because I didn’t perceive the irony/criticism, due to my poor understanding of Swedish! I was happy teaching and encouraged by what the parents had to say concerning the value of prepared birth. Through close contact with the parents after birth, I learned what to improve upon.’
Janette says that now Sweden is on a ‘collision course for conflict! … An example is the manufacture and sale of weapons that bring in huge amounts of money to the arms industry in a country that is supposedly neutral! Sweden had developed from a small country, isolated from Europe, into becoming a part of Europe. She is still influenced by America and at this present time in politics is deep into Thatcherism … People are aware that privatisation has gone too far endangering Sweden’s long established Social Welfare system … There are lots of complaints from patients and parents concerning the National Health Service … There are an increasing number of people turning to the fascist party Swedish Democrats.’
‘I think all this and the huge impact of IT technology (Sweden has the largest usage per person for its population, in Europe) has an effect on birth. It becomes impersonal and theoretical.’
American TV programmes are horror documentaries increasing the fear of birth and being prepared for the worst. She went on to say: ‘Parents want a ‘short course’ where time for reflection and thought is not catered for! Some find the subject of birth too confusing and become anxious about right/wrong choices, sadly leading them to making no choices at all!’
First Water Birth Conference
In 1995 the first International Water Birth Conference took place at the Wembley Conference Centre, with mothers and birth professionals from around the world.
The Active Birth Movement, the Association for Improvements in the Maternity Services and Splash Down water birth services worked together to present data from a new environment for birth.
Researchers, midwives, obstetricians, neonatologists, general practitioners, birth educators, obstetric physiotherapists, sociologists and parents with the experience of water birth came from 19 countries.
Speakers included Dianne Garland, a pioneer of water birth and a midwife supervisor who designed the first under-water Doppler; paediatrician Dr Marsden Wagner; Dr Michel Odent; Dr Paul Johnson, Consultant Clinical Physiologist at the John Radcliffe Hospital in Oxford; Caroline Flint, midwife at the Birth Centre in South London and President of the Royal College of Midwives; Cass Nightingale, Manager at Hillingdon Hospital; Dr Josie Muscat, part of a team that introduced water birth in Malta; Dr Piera Maghella, who founded the Active Birth Centre in Modena; Dr Yehudi Gordon; Dr Faith Haddad; midwife Lesley Page and Jayne Ingrey, the founder of Splash Down. It was a brilliant occasion.
Marsden Wagner said that water birth was branded as dangerous mainly because obstetricians did not have control over it. It represented the social model of birth.
Michel Odent discussed accusations against water birth on the grounds that it was ‘not natural’ and also mentioned that birth under water was reported in a French medical journal in 1804.
Paul Johnson said that if the onset of labour is spontaneous and no drugs are administered a fetus is born with its cord intact into warm, fresh water and does not breathe until it surfaces into cool air.
Jayne Ingrey said that women must have choice. Information is power.
Beverley Beech, one of the organisers of the conference, said that water birth was an alternative to dangerous drugs, and makes it more difficult to intervene in labour. It needed proper evaluation.
Caroline Flint spoke of the birth pool providing a ‘watery cocoon’ for a woman, it affects the balance of power, ‘the woman is in charge’, she is more mobile and ‘inviolate’.
Cass Nightingale stressed the importance of midwives being well trained for water birth and able to deal with any emergencies. In 1994 there were 3,505 births at Hillingdon, and 60 per cent of women used water at some time during labour. It was the primary method of pain relief. ‘Women basically deliver themselves, therefore the midwife should only need to lean over the bath on one or two occasions – to feel for the umbilical cord and to lift the baby out.’
Dr Josie Muscat analysed the results of the first thousand births in water. Perception of pain was on average 50 per cent less in water.
Faith Haddad presented results from a pilot study of water births at the Garden Hospital in London. Most women giving birth in the pool had an intact perineum or only a first degree tear.
Piera Maghella said that Italy had the highest rate of Caesareans in Europe and most doctors per inhabitants.
Yehudi Gordon focused on issues of safety and stressed the need for a complete audit: ‘The enthusiasts are confident that water birth will continue to maintain the safety record which has emerged in the studies.’
Lesley Page talked about surviving the ‘onslaught of the uninformed … Far too many people today assume that more technology has improved the quality and safety of birth.’
Researching Midwifery
In the 1990s midwives in the West developed a clearer view of where their strengths lay. They broke out of isolation, began to link with midwives in other countries, and realised that they faced common problems. Till then a midwife often had little idea of the power politics in the health care system in her country, and even less of the politics in other countries. A direct entry education developed alongside out-dated instruction which saw midwifery as either a top-up to nurse training, an extension of caring for sick people, and a way of producing compliant workers who prepared patients for the obstetrician, kept them quiet, and cleared up afterwards.
In the countries of western Europe EC directives about midwifery training now lay down standards of midwifery. Rather than being handmaidens to obstetricians, midwives should have the education and status to take responsibility for the care of women through pregnancy, birth and post partum. That could never have happened without input from childbearing women, and their commitment to midwifery.
The UK was ahead of most other European countries, larg
ely because of our collaboration as childbirth educators to forge a partnership between midwives and mothers. Through the 90s I taught midwives at universities in the UK and internationally and became Honorary Professor at Thames Valley University.
In Britain the Midwives Information and Resource Service made research much more accessible to midwives and students, and I served on their Editorial Committee.
An important development was research by midwives themselves. In the UK and Scandinavian countries midwives were critically evaluating obstetric and midwifery interventions of all kinds, and demystifying ritual hospital practices. This had a direct affect on care. Enemas and shaves were discarded. A woman could have her partner with her, or anyone else with whom she wanted to share the birth experience, including family members, women friends, and her other children. There were lower rates of induction for ‘post-maturity’, episiotomy rates plummeted, and a more relaxed approach to pushing and the length of the second stage. There was better understanding of women’s emotions in childbirth, and how to provide optimal care for those of different ethnic and cultural groups. Internationally, outreach work was firmly in the hands of midwives, if only because most obstetricians were not eager to work with the poor and did not fancy going to rural outposts. In Australia I explored ways in which Aboriginal midwives were beginning to provide care in their own communities. In New Zealand I discussed with Maori women their concern to rediscover traditional childbirth practices, and incorporate that which was of value into contemporary practice. This was increasingly accepted by Pakeha midwives, who discovered traditions of good midwife care which had been lost in modern hospitals.
The new midwife takes responsibility with confidence, is an educator and advocate for women’s right to make informed choices, and supports them in giving birth in whatever places they select as best for them and their babies. She attends women who give birth at home, and ensures that they have the best care possible. In some countries pilot programmes started up with Government funding. In Australia in 2005 the first midwife-attended home birth took place for which mothers did not have to pay. Yet in many countries the home birth midwife found herself outside the official system. In most states of the United States, the only way she could work was as an underground midwife, risking suspension, litigation and imprisonment
In the Middle Ages midwives had fled to Holland, the only country to offer them a sanctuary. Midwifery there still retains its autonomy vis-à-vis the medical system more than in any other country. A third of births take place at home, and midwives provide total care for normal pregnancies and births. This comprehensive service could not be provided without maternity home care assistants. They help midwives care for the mother, baby and family for up to 10 days after birth, give practical help with breastfeeding, and do the housekeeping and cooking. I learned that these care assistants helped during and after 73 per cent of all births. The Netherlands are the only place where women can rely on this.
Insurance for Independent Midwives is an important political issue for midwives internationally. These are midwives independent of established systems that keep midwives subordinate to obstetrics.
Science And Sensitivity
Lesley Page’s book The New Midwifery: Science and Sensitivity in Practice came out in 2000.64
Midwives need to study the politics of maternity care, how institutional systems work, how power is exercised, and ways in which competing claims for territorial control operate. Then they will be able to join with childbearing women to create a system in which the new midwifery, described in detail in this ground-breaking book, develops and flourishes.
Throughout history and in cultures across the globe a midwife has never been just a technician, someone who manipulates a round object out of a small hole. This has always been recognised in traditional cultures, where the midwife uses her empirical skills, enacts prayers and rites that make the way safe, choreographs the birth drama and the interaction of everyone taking part in it. The midwife’s tasks are multi-dimensional. They involve hands-on diagnosis, treatment, massage and giving comfort, together with understanding the psychology of pregnancy and birth and awareness of relationships and their effect on a woman’s ability to open her body and give birth.
Today the midwife’s role is multi-dimensional, too. She must have up-to-date knowledge of birth-related research and the knowledge to evaluate it. She needs to be reflective about midwifery and obstetric practice in the light of this research. Her practice should be evidence-based. She works not only in a bio-medical framework but with emotional and social aspects of birth. She needs the skills to meld the art and science of midwifery. She gives each woman not only her knowledge, but the personal warmth and caring of a skilled companion and friend.
Any woman who has had midwife care will tell you that it is not just a question of what she knows and how clever she is that matters, but who she is as a person. Research on women’s birth experiences reveals that it is the quality of the relationship between a woman and her midwife that is the single most important factor looking back on birth as a satisfying experience.65 All this research bears out a major theme in the pages of The New Midwifery,66 and mothers’ accounts of their feelings about their midwives are remarkably similar.
Albert Einstein once said, ‘Not everything that can be counted counts, and not everything that counts can be counted’. The quality of the relationship between a woman and her midwife is difficult to evaluate in numerical terms. But this is a vital element in a positive birth experience.
In all cultures the roots of midwifery lie in a one-to-one relationship between a woman and a midwife who is well known in the community and has a life-long relationship with the family, the mother and the child she has helped into the world. In Guatemala, for example, like Nicaragua, the midwife is the ‘grandmother of the umbilical cord’ and, as in many other societies, by her participation in a major event in the life of the family she becomes, as it were, a member of that family. No one needs to plan for this in a peasant society. It just happens. It is much more difficult in post-industrial society, where contacts between people are constantly shifting, ephemeral and superficial, and where close bonds tend to be restricted to the nuclear family, immediate peer groups in a school or leisure activity, and, perhaps, a segment of the work-place.
My own research in a major English teaching hospital revealed that it is often difficult for a woman to get to know her midwife or for a midwife to get to know the woman for whom she is caring.67 Fragmented care undermines their self-confidence. Some felt ‘abandoned’: ‘I was disappointed that the first midwife had to go off shift and leave 50 minutes before the baby was delivered, as I had built up trust in her and had a rapport with her. I didn’t have the opportunity to do this with X in the second stage of labour.’ A woman who had a previous still-birth said: ‘One midwife who knew my history might have made a great difference. They were complete strangers. You ought to know your midwife.’ Women who did not know the names of their midwives tended to have a more negative experience of birth, particularly when they had as many as five different ones. (This may be correlated with length of labour, and numbers are too small to come to definite conclusions.) Those who had a positive experience usually knew the names of their midwives. They said: ‘It was great to have the midwife as my friend’; ‘A positive experience was dependent on having the midwife of my choice who I had built up a relationship with and had confidence in. This can be very hit or miss depending who is on call. I was lucky.’
It is impossible for any midwife to give focused care when she has to rush from one patient to another and relies on an epidural and an electronic fetal monitor to take her place. Women said: ‘We had one midwife covering four women, all close to delivery’; ‘I was left alone for 35 minutes plus while being monitored in the admission room. By the time the midwife returned I was nine centimetres dilated.’ One woman said that each time another midwife put in an appearance she did a vaginal examination: ‘It was the worst
and most traumatic aspect of the birth.’ Women commented on the lack of shared information between midwives and inadequate hand-over between shifts. They had to explain their priorities, if there was time and they had the courage to do so, to each different midwife.
In many hospitals there is a shortage of midwives. As a result, women encounter a wide range of ‘team members’ and care is thinly spread between a vast number of staff: ‘The room felt like Clapham Junction with people bursting in and out and a ward round coming in unannounced’; ‘There was a constant stream of registrars, consultant, house officers, anaesthetists and students in and out of the room all the time’; ‘I felt desperately the victim of the lack of communication. There were too many people.’
Even women who had satisfying birth experiences were appalled at conditions on post-natal wards: ‘All I ever kept hearing was, “Oh, sorry, we are just too busy at the moment’’.’ They had little help with breastfeeding and what there was often incorrect. Many received conflicting advice: ‘I found it very confusing to have different advice from a huge number of midwives’; ‘I never saw the same midwife twice.’ A woman whose baby became severely dehydrated while with her on the ward said that the midwives had no time to help her. When conditions are like this women may be discharged without breastfeeding having been established, with low self-esteem and, in one woman’s words, ‘totally exhausted’. One result is distress after childbirth increasingly recognised as post-traumatic stress disorder.68
Discussion about standards of midwifery care has to take place in the context of the pressures put on midwives within rigid hierarchical structures ill adapted not only to the needs of mothers and babies but also to those of the midwives.
Spiritual Midwifery
A Passion for Birth Page 36