BirthingBetter Skills Resource – some history
Common Knowledge Trust, was created to spread important “common knowledge” to all humanity. One of the types of knowledge our Trust supports is the concept and philosophy that giving birth is an activity and that all expectant families should have the opportunity to become skilled birthing mothers and fathers/others to accomplish that activity with the best outcomes, both subjectively and objectively. The skills we are passing along were developed in the US at a time (1970’s), when there was a societal expectation that families become skilled using Lamaze/Bradley methods and there were few or no choices. This set of skills was discovered and developed by hundreds of ordinary mothers and fathers in the early 1970s with whom I worked as a body worker. Both the concept and the skills are unlike other skills-based methods.
When these skills began to develop, we did not have a concept which we filled with skills. Instead, the skills formed the concept. Every single family had their own good or bad story about their previous birth or the good/bad about their coming birth. Every single care provider impacted every client. Every hospital’s standards of care impacted every family. Every birth that unfolded did so in its unique way. Individuality abounds so much that we forget, don’t see, don’t acknowledge, and don’t work with our commonality. Yet our commonality is much stronger in pregnancy and birth than almost any other Life event except Death.
Here are our commonalities, on which Birthing Better developed a universal set of skills to be learned, practiced and used:
*We all blink, cough, and can tighten up our rectum
*Giving birth is a one-off experience that does not repeat itself and can’t be redone the next day.
*Men and women share the same human body.
*Giving birth is always an activity each woman must do within the framework of her individuality.
Every family wanted these four, very basic things, which are also universal:
FOUR GOALS of Every Birthing Family
*Everyone wants as safe a birth as possible.
*Everyone wants to approach the unknown of their coming birth with some level of confidence.
*Everyone wants to be in control, stay on top of their birth experience as it unfolds, even if they can control nothing that happens to or around their birth except their own behavior.
* Everyone wants to look back on their baby’s birth with dignity and pride.
Sharing a commonality in these four goals meant the broadest group of expectant families would always be included without exception. As the breadth and depth of Birthing Better skills developed, it became apparent that there was a concept that led families to experience success in those four areas: to become skilled! With skills, families could focus on the activity of birthing their baby, regardless of all the unique circumstances.
When I immigrated to NZ in 1995, I presented the concept and some of the skills at the NZCOM Conference and was met with the same resistance I had experienced globally from the 1970s onward to today, when speaking at birth conferences or to birth professionals’ gatherings. Why the resistance to these skills for birth? The concept that skills are essential for birth went out of fashion. In all the years I’ve lived in New Zealand, until I read The Trouble with Women, I had absolutely no idea that NZ had a history of a skills-based approach to childbirth. In the US, it was Lamaze and The Bradley Method. Here it was initially Grantly Dick-Read in the 1950s, in the 1970s it was Lamaze (psychoprophylactic), and in the 1980s Active Birth.
Birthing Better skills are not an extension of Grantly Dick-Read, Lamaze, The Bradley Method, or Active Birth. Instead, the skills were a 15-year evolution that families took part in to create a set of universal skills that could resolve the many gaps each family felt had impacted or might impact their birth experiences.
Gaps, inconsistencies, paradoxes, ironies, conundrums, and confusions abounded. We could not change the system for every individual woman. Nor could we change the personal circumstances experienced by each woman: her health, life, beliefs, family dynamics, availability of care providers, and place of birth. By having an extremely extensive set of broad skills that prepare the pregnant body for birth, and effective birth and coaching skills to cope, manage and deal with birth as it unfolds, then all families could achieve the four goals without exception.
Some More History – NZ and the US, evolution of maternity care
While there had been a societal expectation for 20 years in the US that all families become skilled, there was pressure on the system to change, as there was in New Zealand. Birth advocates became vocal and pushed the system to change. At the same time, in the 1970s famous birth authors were promoting the message that birth is natural, women know how to birth, “cows and cats aren’t taught to birth,” and women don’t need to be taught skills because women shouldn’t be told what to do. Fathers were demoted from being coaches to merely supporting a woman’s choices. The shift from a skills-based approach to an information/choice approach began in the 1970s and was complete by the 1980s. This meant I spent the ‘70s – ‘90s unable to advance the concept that skills are essential to childbirth. No one seemed to see the huge benefits to families and also to birth professionals, that had occurred through the use of skills. How quickly we forget. To “choice” advocates skills seemed artificial and went against what famous authors had said…women should trust their instincts, get into their primal brain, and be left alone to discover birth themselves. I was and still am told repeatedly by birth advocates that I insult Womanhood by implying in any way that they should become skilled.
Both in NZ and the US the skills-based approach occurred in a climate of rigid guidelines of practice. What if a skills-based approach had been encouraged to evolve alongside the choice-based one? There was a fundamental reason this did not occur, and it had to do with the philosophical basis of Read, Lamaze, and Bradley. They associated skills with natural birth, rather than to all births. Without intent, this set up the oppositional issues that have plagued pregnancy, childbirth, maternity care, and continues to play out in New Zealand. Choice was really a vehicle for women to say no to medical interventions. Yet, as NZ midwives and CBEs have been surprised to find out, choice also must include women who want more and more medical care, even when there are no medical indications.
Let me recap that between the 1950s –1970s both NZ and the US had a skills-based approach for those seeking natural birth, but not for all births. This set up unintended negative consequences for women (some succeeded, and others “failed” or didn’t want a natural birth, or circumstances prevented them from seeking one). A belief had formed that women knew what they wanted at their birth, and if you institutionalized “choice” that more women would have a natural/physiological birth. Yet somehow the successes that connected the use of skills to achieving a physiological birth were now considered an insult to the fabric of Woman-ness. A choice-based system thus replaced a skills-based approach, rather than growing alongside. The ramifications of this are still playing out.
This has been about the background of Birthing Better in the context of the US, but now let’s turn to New Zealand. Until recently I had no idea of NZ birth history. In the 25 years I’ve been in NZ I have not heard one midwife or childbirth educator tell me or hint at the fact that there was a skills-based approach to childbirth in the 1950s –1970s. All developed countries pretty much went through a similar evolution within the maternity system from the 1950s – 1980s, (as well as other societal issues such as mental health, education, daycare, family planning, women’s roles, and various health issues).
However, New Zealand alone was able to put in place in 1990 a nation-wide maternity system that achieved all the goals desired by natural birth advocates and dedicated midwives. This could never have happened in the US, with 50 individual states, each with its own education and licensing requirements. No other Commonwealth country has achieved what New Zealand has. Nevertheless, the NZ Midwifery Model of Care has NOT fulfilled the dreams and hopes of midwives and natural birth advocates, which was: to increase physiological birth, reduce interventions, and empower the broadest majority of women to achieve the birth they want and choose.
When you think back on the history of New Zealand – let’s arbitrarily use the 1850s as the formative years of NZ as a country – that’s only about 160 years. Giving 30+ years between generations: 1855-1885, 1885-1915, 1915-1945, 1945-1975, 1975-2005, that’s just a little over five generations. What changes we have seen in such a short period of time! Germs weren’t recognized and known until 1865. Nurse/midwives had no formal training until 1904. Antibiotics weren’t mass available until after WWII, although penicillin was discovered in 1929. My grandmother died of pneumonia at 40 because antibiotics weren’t available. While small pox vaccination was available in the 1800s, whooping cough bacteria wasn’t known until 1906. Polio was still rampant when I was growing up in the 1950s.
The Trouble with Women does not go back as far as the 1850s, but in NZ “from 1894 -1903 15,767 babies under the age of 1 died and 732 mothers, and possibly double that ‘if after-effects are considered.’” (p.10). The Midwifery Act was passed in 1904. Prior to that, neither nurses or midwives had to have any formal training or registration. Then midwifery became tied to being a nurse. The rationale was to set a high standard of health delivery care within the relatively new scientific medical system. In 1865 germs were identified as causing disease and the concept of having clean hands was just beginning to be understood to reduce sepsis. Emerging scientific medicine is considered a life-saver to many for conditions that have existed for many thousands of years, and that still exist today throughout the undeveloped third world.
Shortly after 1904, St. Helens hospitals began to open. They were run by women, and women were delivered by women. Because there were no antibiotics, the concept of cleanliness reached a fever pitch, led by Dr. Agnes Bennett, who said, “Cleanliness was the first weapon of defense against childbirth fever.” TWW, p. 10. In 1920 NZ had the second highest maternal mortality rate in the western world: 6.48 out of 1000 women died from puerperal sepsis. “Puerperal fever took many lives. Mothers and babies were easy victims for illness and disease.” TWW. P. 9. That’s about three generations ago.
Consider how women lived in those days through to WWII. There was no washing machine, no dishwasher, all cooking was done on wood/coal stoves. Food had to be put up because there were no supermarkets, no refrigerators, or freezers. Clothes had to be made, there was no canned baby food, no disposable nappies, and no contraception. There were few cars, and no vacuum cleaners. Women were also coming into hospital (1924 = 58%). TWW, p.11. Hospitals were seen as “clean and safe.” There is no doubt forceps use was to blame for some of the hospital sepsis, but with no antibiotics, preventing or treating sepsis was very challenging.
I’ve spent many years living in third world countries where access to modern medicine is either not available or very limited, and women and babies still die of sepsis frequently.
In 1925 H-Mt20 was put in place that “standardized in a very detailed way the method to be followed by all nurses and midwives.” Domiciliary midwives boiled everything. In 1926, the Nurses and Midwives Registration Board required that trained nurses/midwives implement H-Mt20. As primitive as this system seems today, nurses and midwives implemented these standards on behalf of women, to save lives.
In 1927, Dr. Doris Gordon, “supported widely by women’s groups” mobilized doctors with a special interest in obstetrics to form the Obstetrical Society. One of the paradoxes highlighted in The Trouble with Women is that progressive male OBs were often more supportive than midwives for changes in delivery of service, as well as protocols for how women should behave in labour, and whether their husbands could be present. “When Jane and Jim Ritchie had their third baby in 1961, Jim was present with their doctor’s approval, but against the wishes of the midwife. The midwife was unrelenting for their next two births.” TWW, p. 98.
Remember how hard life was for most NZ women. Most families didn’t have electricity until 1949. Out of kindness to exhausted women, the Labour government introduced 14-day free maternity stay in 1935. “Nurses who dealt with tired and often debilitated women saw bed rest and removal of baby to nursery as necessary measures for the mothers’ recovery.” TWW, p.6.
Skipping another generation, after WWII, the modern way of life became more available throughout society, with increasing conveniences and women not needing to do so much physically demanding work. Yet this is how quickly we forget even in one generation. Given both the statistics for child and maternal mortality and the living conditions of women just one or two generations earlier, some modern NZ women felt they wanted to go back to natural birth. The medical professionals who were aware of the history could not understand.
In 1951, Helen Brew launched what would become Parents Centre. “The case she would present was simply that women be allowed to choose the manner in which they brought their babies into the world. To choose to be conscious or not at the birth of their child, to take their babies in their arms, unwashed, if they wished, to have them by their bedside and feed them on demand. And, if they wanted to, husbands should be allowed to give comfort and support to their wives in labour. There were corollaries that antenatal classes be available where women could learn about their bodies and prepare for natural birth, that no woman be left alone in labour and that labour rooms be soundproof and private.” TWW, p.1. All of this was connected to improving the parent/child relationship.
The main problem here was associating skills with natural birth rather than with all births. Why should only some birthing women be skilled? Since the 1950s many more things have been lumped with natural birth: delayed cord cutting, baby to breast within a minute, birthing is same room as labour, early discharge, being left alone to discover birth, attachment parenting, co-sleeping, no circumcision, no immunization, home school. I learned early on from the families I worked with that just because they want one thing (actually the four basic desires listed p.9), doesn’t mean they want all the other things.
Parents Centre offered “ante-natal education…12 sessions of breathing relaxation and positions and 12 sessions of lectures” TWW, p.14, following Grantly Dick-Read. This means NZ’s first ante-natal education was a skills-based approach to childbirth. Yet, without intent or foresight, and based on only one type of birth being the best, this created problems: skills were associated with “natural” or “painless” birth. Making a connection between skills and painless birth or natural birth set up a natural versus medical birth conflict between women that exists to this day.
Skills should always be associated with all births. Today and into the future, skills for every birth, without exception, must be the foundation for the concept of growing a skilled birthing population. The development of Birthing Better skills by families was founded upon the four universal goals, stated earlier (p.9). The benefits of universal skills for every birthing family are huge:
*All families can have a positive birth experience no matter where they birth, with whom, or what happens to or around them.
*Birth professionals feel less stressed being around skilled families and enjoy their work more.
*The advantageous side-effect is that skilled families can reduce and/or prevent many of the reasons for more medical assessments, monitoring and procedures.
*The greatest benefit is the ability of all birthing women and coaching dads/others to work through their baby’s birth journey using a universal set of skills that work. This means families achieve empowerment by what they do, rather than the type of birth they have.
Two studies in the 1950s reflected the benefit to women (and fathers sometimes) who used skills:
Dr. Henderson’s study,1954: “… of 150 women who practiced relaxation methods (and that would include breathing skills), 50% received no pain drugs, 44% used minimal. Labours were considerably shortened, post-partum haemorrhage greatly lessened and 90% breastfed.” TWW, p.38. Dr. Henderson didn’t believe all labours could be painless. It was a question whether pain was bearable or not. Nor could all pain be attributed to fear or tension. That observation is absolutely true. There are four types of tension and with the exception of conscious tension, the other three are not related to fear: unconscious tension, structural, and stretching tension. Skills can alleviate these types of tension.
Brant study, 1958: Learning childbirth skills was considered a “treatment.” Parents Centre required all women to be recommended by their OB and then they fought for doctors to have the right to prescribe this “treatment” for their clients. In the Brant study “The treatment group required less drugs, were less time in second stage, had a lower incidence of operative delivery, a smaller post-partum blood loss, and were calmer and more co-operative throughout their labours. The babies were in better physical condition as assessed by apgar scale. The striking overall difference in the condition of the babies was quite evident to casual observers present at delivery. Everyone was impressed by the calm, cooperative attitude of the women throughout labour and their reactions at and after delivery.” TWW, p. 77
Here’s where the decision both in NZ and the US that skills were to be coupled with “painless” and “natural” birth began to show inconsistencies and gaps. Associating skills to either of those types of births then naturally grew a concept that some women could not succeed in achieving a natural or painless birth. There were also women who were, and are today, very comfortable with the medical care, yet were and are not encouraged to use skills. There were and are women who need more medical care than they want, and who were and are not encouraged to use skills. Dr. Beggs, TWW, p.44, pointed this out. “There was some some truth in Dr. Begg’s contention that mothers could suffer great disappointment if the expected natural birth turned out to be far otherwise, or if they gritted their teeth through a painful experience determined not to give in and ask for pain relief. Such things did happen. In vain Parents Centre lecturers stressed that there was no need to suffer, that pain relieving drugs were always on hand and there was no shame in asking for them. It was impossible not to be caught up in the enthusiasm of those who had experienced a natural birth, whose eyes shone with the wonder of it. Those who through no fault of their own were anaesthetized and missed the moment of birth were understandably disappointed. Some had a sense of failure of having let the side down. Friends offered comfort. But it was no good. They were outside the magic circle. Not for them the recital to classmates of a triumphant progression of labour. Some mothers, of course, had listened to their lectures with only half an ear, convinced that they could achieve the ideal without too much effort.”
And “skilled support” was an essential component, but this fell to midwives or doctors, because fathers were not yet permitted to be at birth. Now fathers are there, but skills are lacking. Consider then and now:
*Then doctors had to recommend women to the skills-based program.
*Since 1996 when I presented at NZCOM National Conference, NZ is led by such a strong philosophical belief that women don’t need skills that midwives don’t recommend families become skilled. It’s all about “choice.” This played out over three years when a midwife/CBE teaching ante-natal classes gave all couples the Birthing Better hardcopy resource we had then. She was floored that no local midwife encouraged families to use the resource, so most couples didn’t. And she never saw a midwife in hospital encourage the use of skills.
*Then, not all staff or doctors were trained in the Parents Centre’s methods.
*Now midwives have been convinced by two famous authors that women should be left alone to discover birth.
*Then, pressure was put on staff to be the coach/support.
*Now, pressure is put on midwives to be all things to each woman. That is exhausting, on top of everything else they have to do.
*Then, fathers weren’t yet permitted in the labour and birth. This meant women had to self-manage the skills if staff didn’t support them.
*Now fathers are encouraged to “be there” but as a “support” and not to coach, because “you don’t want to tell women what to do.”
*Then, the goal of the skills was to achieve a natural birth rather than to work effectively through whatever birth unfolded.
*Now, by not having the broadest number of families becoming skilled, we limit those who can have a positive birth experience or be in that “magic circle.”
In the 1970s Psychoprophylactive (Lamaze) became the predominant skills-based resource. In 1984 Active Birth became popular. Parents Centre had evolved throughout the country and taken on many of the systemic problems, from visiting rights in pediatric wards to early childhood education. The maternity system had modernized. Some things got better and other things standardized. Panning (placing a bed-pan under a woman so a nurse or midwife could wash her to prevent post-partum infection) was out. 14 day free stay in hospital was out. Fathers were in. Rooming in was in. Types of pain relief and the way c-section was performed changed profoundly. In every modern country there has been a tug between more modern/medical birth and natural birth. Skills bridge that gap. Skills work in every type of birth.
By the 1970s the emphasis of Parents Centre classes also shifted to information/choices and away from skills just as it was beginning to do in the US. TWW, p. 98. “By the 1990s the light that had briefly illuminated childbirth was in danger of flickering out again. Many of the new generation of parents, dazzled by technological brilliance, were ill-equipped to do other than go along with the new technology….Parents Centre for all its growth in 38 years to 1990 can claim to reach no more than a segment of the child-bearers and for many within its own organization the ante-natal training lacks relevance…(Yet) the underlying Parents Centre message..(was) that… helping women re-discover their natural abilities for birthgiving (confers) special benefits for the baby.” TWW, p.132
Parents Centre aligned itself with the home birth movement, consumers and homebirth midwives. The “magic circle” of women who would birth at home (now considered the ideal natural birth) became smaller, and the majority of birthing families was left out. The choice-based approach to birth also has a “magic circle” that leaves out many families. Only by combining choice and skills does the magic circle expand to include everyone. It all comes down to the message families receive from midwives, CBEs, and OBs.