I ended my first article on Catherine Bell’s fantastic concept of a comprehensive, evidence-informed ‘Birth Map‘ instead of a linear, poorly researched ‘Birth Plan’, with a plea to women everywhere:
I have more to say on that. I suggest you settle in with a brew of something delicious.
“Replacing fear with understanding”. Of course this will take generations, but we can no longer afford to turn a blind eye.
One in three women in Australia experience their birth as trauma.
That is simply not acceptable. Postnatal depression is, not surprisingly, on the rise, for women and their partners too. Caesarean rates in this country are soaring at 35%, and show no signs of slowing down. It can feel overwhelming, but that is no reason to do nothing. On the contrary. This is exactly why we need to fight hard and fight now. I’d say “we have to start somewhere”, except that would be ignoring the incredible work of birth workers, educators and advocates everywhere, blazing trails for us to follow and proliferate. We have to keep going. We have to be brave to speak out against the standard, the expected, the norm.
It takes serious guts and I applaud Catherine and the other courageous pioneers like Jo, Zoe, Jerusha and Selina (if you haven’t seen Birth Time yet please fix that asap!) working against the grain to empower women to take responsibility for their experiences and understand their bodies and the way different models of maternity care work with or against them. They simply must understand. They must align their expectations with reality. I am not talking about women lowering their expectations, as we hear so often. I’m saying, that they need to know that if what they actually want is an undisturbed, peaceful water birth surrounded by their children, doula and known midwife, and to be treated like the queen they are, perhaps booking into the nearest public or private hospital for their care is not appropriate. Maybe they need to consider other options.
I, like many midwives and obstetricians, am deeply passionate about supporting women and their people to be empowered to know and trust their bodies, replace fear with understanding, acknowledge their full range of maternity care options and choose a model of care that best suits their greatest need, desire, and personal set of circumstances. But I have struggled to articulate that well. I’ve found that The Birth Map helps women and care providers to do precisely that. Whatever is most important to women, on balance, should dictate what model of care they choose– not their GP (who writes the referral), not their mother, not their significant other (although their concerns must be addressed and considered too), not their peer group, not society urging us to stick to the status quo: i.e. they should just go where most people go, and do what most people do.
No, they shouldn’t. We shouldn’t. That smacks of fear, and an unwillingness to take responsibility for one’s own self and one’s own experiences- an agentic state. The highly medicalised management of birth thrives on this state, and fears it in equal measures. So much so-called ‘informed consent’ and interventions enacted depend on this lack of agency, but it also allows consumers to swiftly blame the health professionals when there is an unwelcome outcome. If they never owned or understood their decisions, were there choices truly informed? Was there ever consent? Women must assume accountability for their truly informed decisions. Health professionals must respect them.
But this is not as easy as it sounds. As healthcare providers, particularly those of us working in the largely fragmented model of hospital care, we become uneasy when there’s little evidence of a woman’s understanding of the reality of her current set of circumstances. In Birth Map terms, where the woman has planned and prepared for her expected (preferred or necessary) pathway, fast birth pathway (baby won’t wait) and contingency pathway (change of plans!), the question is, what pathway is she currently on, and does her map reflect that?
For example, I cared for a woman whose expected (and preferred) pathway had been a calm, positive, intervention-free hypnobirthing experience, and her Birth Plan reflected that. Unfortunately, when I met her she was on the ward being induced for reasons I can’t recall. Her very lengthy birth plan may have worked very well, and been very appropriate had she been continuing on her expected pathway of an uninterrupted, spontaneous vaginal birth- especially if she were in a continuity of carer model with a known midwife or midwives. But she was not. She was not one of the 8% of women in Australia accessing this widely accepted, yet not implemented, gold standard of maternity care.
From the start, she had decided, for her well thought out reasons or by default, to book into the standard maternity model- public hospital care, with ‘random’ rostered-shift-working midwives (like me!) providing antenatal, labour and postnatal care. She was now being induced. Her expected birth pathway was long gone, and she was in a system that simply could not support even her original plans the way she wanted, try as the system might. Her birth was now being medically managed. Had she followed the Birth Map guide, she would have moved to her contingency planning. But she did not have one of those, and she seemed to be clinging onto all her original hopes and intentions for her birth, regardless of the new circumstances. She didn’t demonstrate understanding of the following critical fact:
You cannot have a truly undisturbed, natural birth when you have consented to induction.
We are interfering in the natural processes, sometimes with damn good reasons, sometimes, less so. Regardless of the reason, once you start that process, there’s no going back. Your birth is now medically managed. Certain options may not be available to you anymore, although this doesn’t mean you have to throw your BRAIN (benefits/ risks/alternatives/instincts/doing nothing) out the window and blindly consent to (or rather comply with) every ‘recommendation’. Catherine helps reframe the highly contentious concept of consent, for both women and care providers, as a decision point. This doesn’t change because your birth is being managed. It does mean the parameters have changed, and you must have your eyes open when you go down that path. In fact, you must have eyes open when you go down any path- metaphorically and literally! Sure, there may be some factors presented as non-negotiables in the new contingency pathway, but some may be much more flexible. Women, you need to ask. Caregivers, we need to help women access the right questions (I love the Birth Map for this!), rather than just present her with a mass of pamphlets and brochures to go home with. For better birth outcomes, women must be aware of and consider these decision points, through informed birth preparation with their care providers, and realign their expectations and intentions accordingly.
Our hypnobirthing woman had not done this, and consequently I was very worried about her emotional wellbeing. Her plan had not been changed to account for her new set of circumstances. One of her key points included “Do not talk to me during labour.” This one really stuck with me. Do not talk to her? During a managed, induced, fully monitored labour? In a hospital? This is simply not possible, safe, or appropriate. The second I read that I doubted everything on her plan, because I could not feel reassured that she had a clear understanding of where she was at and the potential outcomes of her decisions on this pathway. Catherine Bell talks about the importance of the trifecta of expectations, reality and support all overlapping and aligning. This makes excellent sense to me.
Now, please. Do not misunderstand me. I am nothing like my colleague, who, seeing I was reading ‘The Birth Map’ scoffed, “And what’s her qualification? It’s not that hypnobirthing b*tch who came here the other day is it? I couldn’t even stay for that presentation, I had to leave.” What. The. Actual…?
Yes, I was shocked too. Unfortunately, my colleague is not alone in her skepticism. Personally, I am intrigued by hypnobirthing and have booked in for a Supportive Caregiver’s Workshop in a few days. I’m super excited. This will help me better support labouring women who do come into the public system with the hypnobirthing preparation under their belts. As midwives, regardless of our own personal beliefs and experiences, our professional standards require us to put the woman at the centre of their own care. That’s the kind of midwife I want to be, and I know I can do it better. If I like the initial training, I’m going to keep going to become a Hypnobirthing Australia practitioner, and run antenatal classes for couples that teach them about positive, informed, physiological, birth and childbearing. Then I’ll take it to the GPs, and then I’ll take it to the schools. I wonder what my ‘Cynical Sally’ colleague will have to say about that!
No matter where I’m working or what I’m doing, I will always encourage women to plan and prepare for birth (and beyond!!). I love that women have birth plans, I just don’t think they’re very well done, most of the time. Why? Because they often lack the key ingredients they need not only to be taken seriously by health professionals but to actually improve their own outcomes: informed, evidence-based understanding, decision-making and conviction. That’s why I love this Birth Map concept for women and health professionals. It gives women the questions they need to ask of us as their care providers, and of themselves. It also provides a starting point for reliable resources to gain this information not just about birth but about the models of care available to birth within.
Friends, I’m not going to lie. This is incredibly complex. Yes it takes time and effort; but all worthy endeavours do.
So what are we waiting for?
#positivebirthmovement #itstime #birthtime #birthmap #informedbirthpreparation #midwifelife #midwifery #maternitycareinaustralia #womancentredcare #hypnobirthingaustralia #physiologicalbirth #birthtrauma #wecandobetter
Thirty-something and Soul-Searching in Suburbia 
Such common sense, it’s hard to believe that someone hasn’t thought of it before. Is childbirth education still even a thing? In my day the Childbirth Education Association actually wielded some authority in the hospital complex, partnered with physiotherapy. It also conducted ‘Where to have your baby’ seminars for couples deciding what model of care best suited their values and finances (woefully limited options as they were). Maybe the UK’s National Childbirth Trust could establish an Australian chapter, pursuing education and reform within Medicare? Or one of our existing maternity consumer organisations (politically loaded history there) could pick up the gauntlet for hospital reform – not just access to homebirth – though it obviously needs to be part of the landscape too.
Too many questions!
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