Birthing Skills
New Zealand has a proud yet short history of having a skills-based approach to childbirth. The US had a more extensive history, in that Lamaze was taught in almost every hospital in every city in all 50 states.
*Safer Childbirth?, Marjorie Tew
Learning skills existed within a “follow your doctor’s order” evidence based system of the day. There were no midwives in the US and there were few or no choices. Yet during those years OBs and nurses saw millions upon millions of skilled birthing women and coaching fathers. Staff did not provide the coaching support in most hospitals. From this significant change in behaviors exhibited by birthing families, the positive changes in the maternity system occurred and there were many.
The three initial skills-based programs had many gaps, including an exclusive focus on achieving a natural birth rather than achieving a skilled birth for all families. Many of the techniques did not adjust or adapt. None of them really prepared your pregnant body for birth on the inside, where it counts. Even today those women who may do Pregnancy Yoga or other external stretching are often told to do Kegel or Elevator or Pelvic Floor strengthening exercises. That’s good for after birth, when you want to tighten and get into pre-pregnancy shape, but makes no sense if you have to get a big, three-dimensional object out of your body. There are lots of “skills” being used today that are totally counter-productive to helping a baby move down, through, and out.
Let’s imagine if all NZ families back in the 1950s had been encouraged to become skilled, no matter where they birthed, with whom, or what happened to, or around their birth. In the US we got closer to that happening. But those gains were wiped out, led by famous authors, birth advocates and supporting midwives who got together to push for systemic change, much of which was good, but which denied the need for birthing skills. The belief was that women are empowered by choosing what they want, leaving the responsibility for fulfilling those choices solely with their caregivers. Birth Plans were developed as a way to express “want” and we’re still trying to achieve this “normal life event” from a solely choice-based approach. In NZ the midwifery profession is so focused on “promoting and protecting physiological birth” that, without intent, they are not focusing enough on improving all birth experiences.
Imagine if birth advocates had recognized how using birthing skills had made a difference. Somehow they missed the two 1950s studies in NZ that clearly show that birthing skills make a positive difference in outcomes. We have unintentionally weakened the marvelous Midwifery Model of Care and its Partnership by setting up unrealistic expectations and requiring no family-led responsibilities. As a result, women have become more dependent on their continuity of care midwife, and do very little to engage in their baby’s birth. Fathers do even less.
Birth worldwide, wherever there is little or no medical care, in every culture, is always considered to be a life or death situation. Until modern natural birth advocates broadcast their ideas about all women being capable of “normal, physiological” birth, all societies recognized that anything that happens in birth is normal and natural, even if it is unpleasant or even tragic. They had no illusions about pregnancy, birth, and the first few months post-partum. Birth around the world still includes a huge amount of suffering by women/men who do not have skills to manage, cope, deal with, or work skillfully through their baby’s birth journey. These facts, easily made known through modern media, make it virtually impossible for the broadest group of modern women to go back to birthing without a high level of medical scrutiny.
However, all families can become skilled through their own efforts, have an empowered birth, and are more likely to achieve a spontaneous birth even in the midst of AMPs, because, as Marjorie Tew’s research shows, there are no risk factors that identify whether a baby can be born efficiently or whether a woman will cope well. We all know women who have many medical issues who easily birth their baby, and other women who are completely healthy who struggle because they don’t cope well. Skills can bridge these gaps.
Often I’ve been told by birth advocates that women won’t learn skills if they won’t stop smoking, move away from abuse, eat better, exercise, etc. In fact, that’s not accurate and the opposite is true. Families are much more likely to learn skills because birth is a one-off that is going to happen pretty soon. It’s not a lifestyle change, and more families will learn skills, even if the purpose is to fill their boredom, decrease their anxiety, stop feeling as passive and have something to do to fill time. This is the difference between seeing skills associated with achieving a type of birth rather than seeing birth as an activity that is best done with skills (like driving a car)!
I’ve also been told that Birthing Better skills don’t work because they didn’t reduce this person’s c-section rate, or increase natural birth. The goal of Common Knowledge Trust and Birthing Better is not to reduce c-sections or increase natural birth. The goal is for families to have a set of skills to use while birthing their babies. In other words, skills don’t have to be perfect, and any skill is better than none.
A doula I know has been persuading all her clients to self-learn Birthing Better skills over the past five years. Prior to that, 30 – 40% of her clients had a c-section. Now, for five years, the only c-sections have been for breech. This was not a goal, but a happy side-effect of families learning skills. Here are some points she has raised, in the form of questions to consider, on the value and use of skills for birthing:
*If a woman and her partner knew how to open her pelvis a little side-to-side or front-to-back, to let baby slip through, would that be a valuable skill in certain births?
*If a woman and her partner had worked to release unconsciously held tension in her birth canal prior to labor, enabling a quicker descent and birth, would that be a valuable skill? (no more “stuck” babies – no long second stages).
* If a woman and her partner knew how to manage her pain and work with surges with visualization based upon her own anatomy, thus reducing the length of first stage, would that be valuable?
* If a couple had practiced a common body language and touch before labor so that there was an intimate, trusting, helpful communication between them, translating to greater intimacy and trust after birth, would that be valuable?
*If you find yourself saying, “We tried everything, but nothing worked,” to prevent the last c-section in your midwifery practice, that indicates a profound need for specific baby/body-relationship skills, which is what Birthing Better provides.
Autonomous Practice/full scope of practice
I discovered in Women’s Business That there are three different usages of the word “autonomous:” It can be used to designate a professional organization; to describe someone working individually, separate from an organization; or to describe someone paid individually, separate from an organization.
The midwifery professional body is independent of nursing and other medical professionals. The professional body does not identify midwives as medical professionals. The funding for community midwives is separate from DHB. Individual midwives work separately from one another.
Have our midwives put themselves into a corner by insisting they are always autonomous, “held to her own professional responsibility,” non-medical, not needing to work in a team, not wanting to share continuity of care, serving the whole population while promoting and protecting one type of birth?
Consider these questions: How does an autonomous midwife work alongside other health professionals who see themselves as a team? How does a non-medical midwife work alongside other medical health professionals without being seen as “less skilled”? There are advantages and disadvantages to each midwife working autonomously. CBEs do, too. This means that each consumer is faced with individual providers who work independently of one another, and the consumer may not know this. Consumers will receive varying information and approaches to their coming birth from different autonomous midwives.
WB: “Self-employment meant midwives could utilize their full scope of practice according to the needs of women, rather than according to priorities of hospitals or the needs of employers…”
Scope of Practice: “Midwife works in partnership with women on her own professional responsibility, to give women the necessary support, care and advice during pregnancy, labour and the postpartum period up to six weeks, to facilitate births and to provide care for the newborn.
“The midwife understands, promotes and facilitates the physiological processes of pregnancy and childbirth, identifies complications that may arise in mother and baby, accesses appropriate medical assistance, and implements emergency measures as necessary. When women require referral midwives provide midwifery care in collaboration with other health professionals.
“Midwives have an important role in health and wellness promotion and education for the woman, her family and the community. Midwifery practice involves informing and preparing the woman and her family for pregnancy, birth, breastfeeding and parenthood and includes certain aspects of women’s health, family planning and infant well-being. The midwife may practise in any setting, including the home, the community, hospitals, or in any other maternity service. In all settings, the midwife remains responsible and accountable for the care she provides.”
Thesis by Helen Donald, 2012, Work/Life Balance, p. 39: “Flint (1986) emphasized the empathy provided by the midwife in a close relationship in this holistic approach: ‘To be a midwife is to be with women – sharing their travail and their suffering, their joys and their delights. To be a midwife is to engage in a close and intimate relationship.’ Flint goes on to say, ‘the midwife is the cornerstone of the emotional health of the whole community.’”
This is part of the misconception about who birth attendants have been and are, worldwide. In India, midwives come from the untouchable class because they can touch body waste. They are not highly regarded. They come at the end of the birth and clean up. Tibetans know the word “midwife” but they don’t have any. Anyone who is present at the birth helps. In many cultures either the woman goes off by herself, or with her family members, or births in her home with others around. If there’s a problem, usually a spiritual healer is called. Throughout the world the “intimate relationship” comes from the woman’s own family, not the midwife. Even in Holland, where midwives have a client load of approximately 120 women/year, they have this idealistic and unrealistic belief.
This is why growing a skilled birthing population is so important. Self-learning skills is something families do for themselves. Birthing skills are what they bring to their birth. Their skills are how they behave, cope, and manage this dynamic experience. All humans feel empowered by being skilled. It is uniquely a human experience to know yourself as a skilled person. Synonyms are: clever, competent, efficient, capable, fitted for whatever lies ahead. Antonyms are: bungling, awkward, inept, incompetent, and untrained.
Even in the few communities that have traditional birth attendants where I’ve lived, worked (not in birth), or visited to share these skills, none of them wanted to be responsible either for teaching or doing the skills. They all want the families to self-learn, practice and use them, because, they say “If something goes wrong, we are already blamed.”
Expectant parents are adults. They are old enough to learn birthing skills on their own, and they are mature enough to appreciate the sense of accomplishment that brings. There is no good in expecting women to be incapable of self-learning birthing skills. In the Partnership, this simply invalidates their role and diminishes it to the level of a non-contributing partner. No wonder midwives are tired, over-worked, and many are leaving the profession altogether. There really is no traditional precedent of 24/7 midwifery care for all women, in any society. To offer it free is a great public service seemingly, but in practice it breeds dependency of the population upon a group of public servants (midwives) who are increasingly subject to burnout from overwork. Again, a partnership must be balanced, with both sides having responsibilities and duties to fulfill. Then most of the problems we see today with the lopsided model will balance out.
95% Happy
WB, Accountability chapter: “The MSR consumer feedback process is so successful that in 2010 some 25,000 women on average return(ed) forms to the College for their midwives’ review. Over 95% positive, with minor issues, usually about behaviour and communication rather than competency. Less than 1% have practice issues identified by the NZCOM that require following up.”
WB, p.239. Conclusion of reviews. “…these reports about the maternity services, conducted over 19 years, remind us that continuity and choice has always been important to women. In the late 1980s, women stood resolutely to demand the right to make their own decisions over their maternity experience. The DOH initiated the actions and structures that facilitated this and over these decades every review that has been conducted has upheld the reasons for the changes to the maternity service. Importantly, none has identified any significant issues with the system that has developed. However, institution(al) memory is lost through successive restructuring of the MOH when roles are reallocated or the advisors with knowledge move out of the maternity sector as contractors move in.”
How does being happy relate to the huge increase in the c-section rate? Midwives are overwhelmed and leaving, but women are happy. Wouldn’t you be happy if you had one dedicated person, paid for in full by the government, who are there for you 24/7? When families learn skills, their dependency decreases. Regardless whether their pregnancy/birth is straightforward or very complex, they have a set of skills and only seek health care contact when it suits them.
Interventions, or Assessments, Monitoring and Procedures?
When we make the magic circle very small, we say that in order for a woman to achieve a natural birth, there can be no interventions. But what is an intervention? Is Pitocin an intervention and drinking castor oil to start labor is not? The very word itself implies an interruption of a natural process. This pejorative association tends to exacerbate resistance to what are simply, otherwise named assessments, monitoring and procedures? Good maternal care is founded upon making correct assessments of the progress of pregnancy and the unfolding of the various stages of birth. Monitoring is just one way to keep a close eye on what is still invisible, to make sure all is well. Procedures may well be optional, depending upon hospital protocols, and can be opted out of. Some are medical, and with informed consent, families can decide whether or not they are necessary.
No matter what types of assessments, monitoring and procedures are introduced, birth and coaching skills practised by families WORK in maintaining focus upon the birth, managing emotions and negative thoughts that may arise, getting on with the task at hand, and helping baby’s efforts to be born.
FEAR
Having lived for many years in traditional communities where there is little or no modern medical care, everyone is “fearful” during pregnancy and birth. But fear and “heightened awareness” are on the same nerve paths. People in traditional communities become hypervigilant during the pregnant, birthing and newborn periods. I’ve come to understand that telling women not to be afraid is akin to telling them to lower their awareness and vigilance concerning the welfare of their babies.
A way to help women to develop a lifetime skill from their anxiety and hyper-awareness is as follows:
*If a woman is anxious or fearful in pregnancy and birth, does she feel something is going to be dead in 5 minutes? If yes, seek help immediately. If no, ask this question:
* “Do you think something is going to be dead in 12-24 hours?” If yes, seek help right away. If not, pay attention and ask this question:
* “If something isn’t going to be dead in 5 minutes or 12-24 hours, are you anxious or do you need to pay attention?” If you’re anxious, then acknowledge it, take a deep breath, and accept that you feel anxious. That’s OK. If you need to pay attention, then do so until it’s resolved. Either you seek help, or things come right.
* In other words, the heightened awareness serves an essential purpose of paying attention. That skill serves all mothers and fathers when dealing with the non-verbal messages given by newborns and babies.
Actions Going Forward
Growing a skilled birthing population will never be consumer driven because women are “happy with the system.” Parents Centre and a small group of midwives and some consumer advocates changed the system almost 30 years ago. The model is viable, and puts NZ in the forefront worldwide of enlightened maternity care. The only tweak we need is to balance the partnership between midwives and women. Birthing skills do that, and according to midwife Andrea Vincent, if promoted by all midwives, our c-section rates could be dramatically lowered within two years.
Do we let people have accidents while driving because they didn’t “ask” to be taught the proper driving skills? No, we inform everyone that in the potentially life-or-death situation of driving a car, you must learn skills, and be tested for knowing them, before you do it. Birth is also a potentially life-or-death situation, more so for third-world families, but also in a small number of tragic cases here, too. Skilled families avoid the “accidents” of birth and come through, even when many medical procedures have been deemed necessary, with a personal sense of triumph at having managed themselves well.
With skills, perhaps the various descriptors for birth now in use, such as “natural,” “normal,” “physiological,” “vaginal,” “c-section,” will be replaced with words like “good” or “better” or “wonderful” or “great,” derived from the Birthing better skill-set. How your baby comes into the world is very important, and each family wants to meet the challenge of birth in the best way. Educating the population as to the efficacy of birthing skills will plant the seed of desire to learn them before labour. The regret of hindsight is painful to endure, often much more painful and long-lasting than the duration of labour. Skills obviate regret: when you learn skills and use them, you know without a doubt that you have done your very best. Babies are also aware of their parents’ desire to help them and learn skills. Thus, becoming skilled is one of the first building blocks of trust in the bonding process between mother and baby and father/partner.
There are many life skills which are worthy of becoming part of humanity’s “common knowledge.” To disseminate them is the reason for the establishment of the Common Knowledge Trust. Birthing skills are just one aspect of its mission. Don’t have any illusion concerning the original hundreds of Birthing Better families. They were strongly faith-based and 99% were very medically high-risk, from all socio-economic strata. Every family had its own belief system and situation, yet we discovered we could organize a set of skills around some simple Truths: we share a human body; giving birth is an activity.