Midwifery and Doula Work

I just found out that another student graduate of the MBC Doula School has been accepted into Ryerson midwifery school. She will make a wonderful midwife and I truly believe that the experience she has had volunteering for Montreal Birth Companions has given her the groundwork that she needs to start her midwifery education with confidence and compassion. I hope she can be inspired by my friend Robin whose midwife life is documented in this wonderful film:

I have been involved in maternity care since I was thirteen, which as my youngest son likes to point out, was a very long time ago! For years, when my four older children were small and I was running an organic subsistence farm, I studied Clara Hartley's "Apprentice Academics" long-distance midwifery courses, and so I gained my theoretical background for woman-centered care. When I returned to Canada, I chose to attend births as a doula and I continued to learn from every woman I accompanied, and from every professional I met.

I have been part of programs that offer midwifery internships to students in parts of the world where midwives is scarce and hospitals are under-equipped and expensive. This phenomenon morphed into programs in the southern US that provide midwife-based maternity care to Mexican women, and it also became a popular way for student midwives from the US to "get their numbers" for the Certified Professional Midwife program administered by NARM. This practice has now been discontinued because of ethical considerations, which makes it even more difficult for midwifery students from North America to have contact with women from cultures outside of their own. 

Midwifery programs in Canada are not apprentice-based, and the university programs that teach Canadian midwives do not expect students to go to the community to gather their birth experience. Practical experience is combined with theoretical study to provide the students with a grounding in midwifery in Canada. 

The requirements for graduation vary slightly from province to province, but generally a graduate midwife must have attended "a minimum of 60 births, acting as primary caregiver for at least 40 births in home and hospital settings." (http://www.ryerson.ca/midwifery/overview.html)

A student midwife can learn a lot from participating in the births of 60 babies. As every birth is different, the student will see, hear and learn about many variations to the tune of giving birth. If she is primary caregiver for 40 births, hopefully she will attend ten home births, and possibly have to transfer one of those to the hospital.

But I propose that prospective midwifery students in Canada and around the world can greatly benefit from a foundation of learning and experience that they will find by volunteering as doulas for needy women.

Why? 

First, volunteering as a doula can teach a midwifery student about an important aspect of midwifery, an aspect that is not taught in class and can only be learned in practice - and even better in doula practice! This is the art of sitting on your hands: "Don't just do something - sit there!" is one of the golden rules of being a true Birth Keeper. Doulas working in hospitals alongside medically trained professionals need to be able to keep their opinions to themselves. They need to learn how to act diplomatically in all sorts of situations. They need to learn how to comfort, how to heal, how to facilitate natural birth with only the lowest technologies. They learn how to measure cervical dilation with their eyes and ears. They can distinguish between normal pain in labor and suffering. They are adept at hearing the little catch in the breath at the peak of a contraction that means that a woman is nearing the pushing phase. They can sense the difference between the "6 cm rectal pressure" (when a woman probably just needs to have a poo); and the fully dilated deep pushing urge.

Why are these skills important for a midwife? Because the art of midwifery rests on a foundation of physiological childbirth. And the more a midwife knows about how NOT to disturb the birthing process, the easier her task will be. Then when she starts her midwifery classes, which teach her the skills that doulas are not trained in, she will already have the very basics of birth attendance.

Secondly, as a volunteer doula with an organization such as MBC, the midwife-to-be will come into contact with women from many backgrounds. She will witness birth experiences that will be as different from each other as every woman's story. She will find herself listening to women's stories from around the world, and she will learn about herself as a woman and as a birth companion. She will learn about professional boundaries, and about the challenges that women face when they are marginalized.

As a Birth Keeper, I have witnessed many births and I have been part of many more, as coordinator of MBC, as shoulder to cry on, as mentor. I have learned from books and from my teachers (Basia, Ibu Robin, Heather, and others). I have learned what NOT to do from other teachers - and those I won't name - but I have witnessed midwives, nurses and physicians who have treated birthing women with disrespect and brutality. 

But the most I have learned has been from the birthing women I have served. And this is why I believe that volunteering with an organization such as Montreal Birth Companions should not be an aid to midwifery school acceptance, but a requirement.

Burnout

Mama and son in Barbados

 Mama was happy.

This story is about burnout. About that feeling you have when you have so many worries and brightly colored post-its stuck inside your head that you mainly just walk around your house looking at things.

My particular form of burnout started in December, when my mother came to visit with a large parasite on her neck. Cancer is weird that way. This thing just grew and grew and grew until it just sucked her away.

I made her a party for New Year's:

L'Chaim!

Then I got back to work. In January, I organized a big doula workshop with my friend Debra Pascali-Bonaro. It was wonderful, all things doula, all the doula students ... the hotel was crap, I learned my lesson about cheap hotels. The food was great - having a chef for a son is a bonus (yes, I paid him). 

I also attended five births that month. I realized during some of those experiences that I had to stop attending hospital births for a while. I couldn't bear to see unnecessary things done to women by people who had not bothered to educate themselves about the birth process. 

I studied like crazy for my CPM written exam. When my second son (the boy in the picture!) was born 28 years ago, I realized I wanted to become a midwife. Not because I had a wonderful birth experience but because in fact I was horrified by the approach and the touch of my birth attendants, and I was drawn to treating women with love.

I wrote my exam, and I passed!!! Now I am a Certified Professional Midwife. 

Then the parasite on my mother's neck took over my life, from February until March when she finally passed away, I was caring for her, sometimes from a distance, sometimes right by her side.

Home death isn't all its cracked up to be. Death can be pretty awful, really. I've seen death and its never so nice, but my mother's death was hard. 

And so to mourning and grief. In the Jewish faith, you just sit for a week and don't do anything. This is good. Then for another three weeks your activities are limited. This is also good. 

I have taken good care of myself over the past month. I realized that some of my big disappointments over the past few months are really little - the rejection slips piled up, so? So I started running again, back up to 4 k, and working on it. I want to get to ten by the end of the summer. I eat well. I try to do fun things. I cherish my kids and my family. 

What is the cure for burnout? Be gentle on yourself! This means being able to walk around the house and look at things. To stand in the middle of a room and think for a few minutes. To have a piece of chocolate. 

It also means saying no when you need to. Not always, but when you need to. It means making sure you have a couple of friends you can call when the going gets tough. It means not taking yourself too seriously. It means pushing yourself to get some exercise. It means starting slowly to get yourself back at work and play, but starting! Start off slowly if you need to, but you will need to. Burn-out can't last for too long, because then it becomes chronic tiredness and pain or illness. Treat yourself like a pussy cat for as long as you can, but when its time to get moving again, you will know it.

This particular pussy cat is so happy to be back from the edge! My energy is solid and growing. I am back in the birthing room, after some time away. I have my patience back. I am looking forward to an active and productive year, as the MBC Doula School blooms and MBC continues to provide service for those who are in need. 

Thank you for traveling with me for these past difficult months - the list is long, you know who you are. 

Bad Science, Bad Medicine, Bad Luck

I am actually enraged this morning, and I have been since last night. It's just no good any more to pretend to be kind old Mrs Tiggy Winkle, and watch women being abused over, and over, and over again in our worn out medical system.

A few weeks ago, I witnessed a natural, speedy delivery. The woman was effectively pushing in a supported squat. Enter the doctor, who cannot catch a baby from underneath and pressures the woman to lie down. A small shoulder dystocia develops. Doc pulls on the head like there's no tomorrow and breaks the baby's collar bone.

That same week, a foreign lady let me know that an OB at the same hospital has been charging her $100 cash for each prenatal. Here in Canada, that is ILLEGAL.

She labors beautifully, and is almost delivering, when the doc suggests an episiotomy. This was the one thing, the ONE THING, that my client was terrified of. Luckily, she pushed the baby out with the next contraction.

Move forward, random thoughts: A client was in the hospital for twelve hours. During that time, she saw about ten medical professionals. What do you think the most-asked question was: How are you feeling? Nope. "Do you have any questions?" Nope. "Is there anything you need?" Nope. It was "Have you had any miscarriages or abortions. Well, it's not rocket science to figure out that that may not be the best question to ask a laboring woman for two reason: One, she may not want everyone in the room, including her partner, to know. And, Two, these are painful memories that she may not want to think about.

But yesterday takes the cake.

Lady is being induced, medically necessary induction. Gets put on the pit. She's 2 cm. Then in five hours, she's seven cm! And then two hours later, still seven cm! They are talking AROM, so my client wants me to come to the hospital. Fine.

She's laboring so well, not feeling her contractions at all. I have seen this, infrequently, but I've seen it. The doc wants to AROM, but since she's seven cm, she decides to wait it out.

Finally, in the evening, another physician comes in and checks her. She's two.

Discussion. Justification "your vagina is a funny shape". "She's a good resident so we don't check her results". Even when those results are difficult to believe? Really? Then, a peace offering. You stay here and sleep, we'll start the induction again tomorrow.

Bad Science: why the induction? check your results, and especially check a student's results. Have a look at how you're playing with the insulin and oxytocin.
Bad Bedside manner:  Is it necessary that a woman not eat for days? Is it possible to at least make eye contact with the doula, so that she doesn't feel like shit when she leaves the hospital? Are you going to apologize for your mistakes?
Bad Luck:  How often do iatrogenic errors lead to major consequences?

Where is this all leading? It's not leading to a rise in home births, at least not in Quebec. I was speaking to a midwife yesterday from another country who has witnessed over a thousand births, and she is not certified here and therefore is not practicing. There is no bridging program that effectively allows for CPMs to become certified here in Canada, so we are left with a lack of midwives and an overburdened hospital system where errors frequently can and do happen.

Comments? What are YOU doing to change obstetrical care in your community?