Safe Birth?

These days, we have all become experts at reading articles in medical journals, or studies, and we casually use words like "exponentially" and "virus shedding" and "evidence-based". So, I am not going to go that route again, and quote this or that Cochrane review that will further convince you that I'm right. I don't even want to think in terms of who's right and who's wrong. I want to go deeper than that. Way deeper. I want to explore what makes birth sacred, and what keeps it sacred, and therefore safe.

I have witnessed three newborn deaths in my doula practice. Two in particular stand out for me. One took place in a birthing centre, and the birth was attended by midwives. I was the doula. When it was clear that the baby was in serious trouble, the midwives, in their fear and panic, became insensitive to the mother's emotional needs. They told me, the doula, to leave. Mother felt isolated, abandoned, and traumatized even more than she had to be. These midwives, don't get me wrong, did everything they should have done medically, to try to save baby's life. But they completely ignored the spiritual, emotional, transcendent nature of birth. Conversely, I was present when another baby died soon after birth in the hospital. The medical staff provided a space where the parents could hold their child and say goodbye. The parents wanted me there, so I hovered, as a good doula does. The fact that they even had spiritual needs was fully honoured by the doctor, the nurses, and the orderly. 

Both mamas lost their babies. Both mamas grieved. But both mamas were not traumatized for years. Because one mother felt safe during her birth experience, and the other did not.

So, what can we do to keep birth sacred? I believe if the sacred nature of birth is remembered at all times, then the attendants will be naturally drawn to keeping the mother safe at all times. Sacred. Just play with the letters a little bit. Scared. Being scared during childbirth is something that has a physiologic root. When our bodies release the stress hormones that initiate the "ejection reflex", our busy brains interpret those feelings as "scared". I have attended the most natural, undisturbed, physiologic births where I have seen the mother become afraid at that moment. It passes, it's transient because it's just a reaction to a physiologic event.

But I've also attended too many births where the birthing mother was actually afraid. She was actually made to feel afraid by the words or actions of her attendants. I often found my job as a doula to be one of shielding, holding the sacred space, creating a human sound barrier between the abusive staff and the birthing mama. Scared destroys sacred. It degrades sacred, pulls it down, tears it apart. Scared does not belong anywhere a mother is giving birth. Even if you're the primary attendant, and you are scared because of something that's happening, your priority is to keep that fear from entering the space.

If a birth attendant doesn't believe that birth itself is sacred, then we run into problems. If you think it's just another medical procedure, then it makes it more complicated. But every doctor knows that a happy patient heals quicker and better than an angry or lonely one. So even if we're not talking "sacred" because some people are scared by the word, we can still try to keep the birthing mother happy, right? And a happy mother feels safe.

Our maternity care system is broken. Too many women go into the experience with no understanding, and they trust their medical caregivers of course, because why not? And they are sadly betrayed. They're told all sorts of scary things: your baby is too big, you're too old, you have a something percent of this or that horrible thing happening, you won't be able to stand the pain, your baby is too small, you live too far for a home birth, there are no midwives, you have to pay $10,000 before you can even think of birthing here, and on and on. Many, many women give birth just fine within the medical system, often with the loving attendance of a doula. These women are a testament to the strength of the birthing mother. But too many do not give birth just fine. They leave the hospital or the birthing centre traumatized and confused. Some traumatic birthing experiences literally take years to recover from. Other women live their whole lives with feelings of inferiority and a damaged sense of worth. Still others spend their whole lives to make the birth experience sacred and safe for other women (Yours truly!). 

There is a growing number of women who are taking the situation into their own hands, and their own homes. They are saying "no" to maternity care that is based on fear, and they're giving birth on their own terms, in their own homes, with people around them who they trust. Keeping birth sacred. 

I don't believe a normal pregnancy and birth belongs in a hospital. Hospitals are places where you go when your health is at risk, or you need surgery. Normal birth is sacred and belongs at home. The undisturbed mother feels safe, and everyone around her participates in the sacredness of the event. This has become clear during the current crisis, where the role of the hospital has been clarified by the event. 

But if we bring birth home, where it belongs, then are we sacrificing another kind of safety? If we don't have midwives who are trained in the art and science of attending Sacred Birth, then every home birth will be a "freebirth". Which is fine for those mothers who want that. But many birthing women want to have someone present, who knows about the things that can and do happen during birth, when it is important to have someone attending who knows how to respond.  

I'm asking questions. I don't have practical answers yet. I am grateful for you doulas out there who are still attending births in the hospitals, and I strive to support you as much as I can. I am grateful to the birthing women I attended throughout my practice, who taught and continue to teach me so much about Sacred Birth. 

Let's talk this out! Let's strive for answers! Let's change birth and keep it Sacred!

A Crack in the System

A couple of years ago, when I was deeply into my work at my cafe, and running longer and longer distances, I told my husband at some point "Yeh, The Man won." I meant that crippling internal conflicts had brought me to a decision to abandon my volunteer doula organization; that the arrest and conviction of unregistered midwives in Canada and around the world meant that women were left with less and less choices; and that my simmering suspicions about the nature of feminism were possibly true. 

So, I took pleasure in my cafe. I ran faster and had a load of fun doing races. I made new friends. I ignored the birth world, and only answered a call if one of "my" students had a question about a birth or a pregnant client of theirs. Occasionally I would check in with midwife friends around the world, just to check in. I was happy giving it all up. I put my doula bag away and forgot about my plans to go back to Greece to attend women in the camps there.

Then that crazy virus hit and I spent two month at home, with my family (husband, two sons, nephew). I made myself a small cocoon, and I crawled into it and meditated, thought, wrote and pondered. And then women started calling me. Women who had planned to give birth at home but whose midwives were forbidden to attend. Women who planned to give birth at the hospital but their doula were forbidden to attend. I gave advice, gave comfort, affirmed choices, made suggestions. 

I met with a few women who were planning to give birth in their own homes, without a midwife in attendance. I spoke to them after their births and got the idea I would interview them for an article or a podcast episode. Then I looked at the footage and I realized - you women are amazing by the way! - that I have some beautiful, inspiring footage. And then I realized, yes well, women experience less-than-optimum births and they're also worth interviewing....

So, now I have interviewed about thirty women, I have so much beauty on my Google drive and so many words of wisdom... so I'm making a documentary to celebrate our strength, tell our stories and let the world know that our care of the birthing woman needs change and needs it NOW!

There is a crack in our maternity care "system" and women are falling in. Luckily, the Covid crisis is a chance for us all to have a little time to check in with our reality and make some changes. Fast. 

Some questions to ponder:

• Why are women expected to "reach for the top" in their professions and then called "too old" when they decide to bear children?
• Why are women expected to go to the hospital to give birth? As we now know, hospitals are where sick people go. Pregnancy is not an illness.
• Why are women threatened with the death or morbidity of their babies, while they are in labour?
• Why are there so few midwives in Canada?
• Why are doulas so expensive? Is a birth companion a luxury?
• Why do women feel ashamed for their birth experiences?

And some mantras to reflect on:

• Nature is not gentle, it is powerful and untameable.
• Heal birth, heal earth.
• Powerful women can change the world.
• Just a reminder, when a woman gives birth, she is BIRTHING A NEW HUMAN! 

So, I have my work cut out for me, and I am feeling good.

If any one of you wants to participate in any way, let me know: do you want your voice to be heard? Do you want to be involved in production? Do you have an idea you want to tell me about? 

I'm listening!

A Response to Dr Gawande

Dr. Atul Gawande's article in the New Yorker, "Slow Ideas"  has been spreading like wildfire on Facebook and elsewhere in the birth world.These are important ideas about change in maternity care and care for women and children overall. Everyone likes his ideas about woman-to-woman communicating and grassroots movements and bringing change one woman and baby at a time.

I read the article and I had serious problems with the language, first of all, but also with the overall set of assumptions about how "we" care for women and their unborn or newborn babies.

Here are my thoughts:

Why did Ibu Robin Lim win the CNN Hero of the Year award in 2011?

Ibu Robin has been working for nearly twenty years in Indonesia, offering free maternity care to women who would otherwise be giving birth at home, in unsanitary conditions, and possibly without attendance. She is on excellent terms with the hospitals in her area, and has single-handedly changed the face of childbirth in Indonesia.

While the goals of the Better-Birth Project are laudable, the inconsistencies in Dr. Gawande’s approach to better childbirth practices need to be addressed. First, there are several simple facts that are misrepresented in his article (“Slow Ideas”, July 29, 2013). For example, it is simply not true that “many babies cannot take their first breath without assistance”.  About 10% of newborns need assistance with their first breath, and around 1 to 2 percent need resuscitation ("Most newly born babies are vigorous. Only about 10% require some kind of assistance and only 1% need major resuscitative measures (intubation, chest compressions, and/or medications) to survive". (Textbook of Neonatal Resuscitation, 6^thedition, American Academy of Pediatrics, p. 39).

Secondly, serious obstetric emergencies, such as shoulder dystocia (rare and potentially fatal, and often unpredictable), are lumped together with common phenomena such as a cord around the neck (around 30% of neonates are born through a nuchal cord). This speaks of an approach to childbirth that is steeped in the western belief that childbirth is an emergency that must be prevented.

It is this approach that will not bode well for underdeveloped countries and their attempts to save mothers’ and babies’ lives. Dr. Gawande describes an effective program: women on the ground, moving from village to village, teaching simple practices that will help to save thousands, if not millions, of lives. But why stop there? Perhaps we can reduce the “twenty-nine basic recommended practices” to just ten. Actually, these 29 practices are only part of an initiative sponsored by the World Health Organization, that is studying the efficacy of a checklist in reducing infant/maternal mortality. It is not yet recommended practice, or even yet proven to be effective . "The formal trial began in 2012 to measure the impact of the Checklist on severe maternal and newborn harm ... Data collection is expected to begin in 2013 and will continue for a period of three years. It is estimated that the study will be completed by 2016."

At the end of his article, Dr Gawande suggests that what made a difference, in one particular woman's life (she was a nurse), was that the expert who was making suggestions about how she could change her approach was friendly. "She was nice." A vision of maternity care that works is a vision that certainly reduces maternal/newborn mortality and morbidity. But it must also be a vision that includes respect for women and their babies, their families, and their culture and history.

I believe that Dr. Gawande’s vision must be taken one step further, and that with just a little more courage and the kind of round-the-clock dedication that I have seen at Yayasan Bumi Sehat in Indonesia, we will start to see dramatic changes in maternity care around the world. We have to reduce the fear of childbirth, and the institutionalized fear of "untrained birth attendants". We can, instead, work with what we have - integrate ten or so better practices into the TBAs practice. Create better and more efficient, low-tech tools for TBAs to carry. Integrate the technology we DO have - mobile phones are used extensively all over the African continent, for example, and find creative ways to save lives. Reduce high-tech interventions. They don't work unless the infrastructure can support them.

Turn your held beliefs on their head: It is certainly a triumph of modern medicine that we can be vaccinated against tetanus. I always keep my vaccine up to date: the old lady who lived at our house in Italy years ago died from tetanus after being pricked by a rose! It is a horrible way to die, and once a wound has become infected, it is incurable.
Newborn tetanus kills babies, every day, in many countries in the world. The tetanus bacteria enters through the umbilical cord, either from unsterile equipment or unhygienic after care.

What if we didn't cut the cord? No wound! No tetanus!!!

Let's work together to find answers to this daily tragedy: mothers and babies deserve better.