Rest, Recovery, Reflection, Renewal?

I am sitting on a hilltop in northern Italy, rather completely on my own. My dog is here. I'm surrounded by insects, animals (deer, wild boars, the odd wolf, badgers, and all that). I planned for a very active summer, running at least 40 k a week, which I love doing - running long distances is literally my happy place. But then some stuff happened and I got Covid and now I just feel cellularly tired. So every day I spend quite a few hours just sitting staring out at the view. 

And what I've been asking myself is that difficult, age old question: Who Am I?

When you spend hours alone, especially in a spot where silence is the overwhelming sound, you get a chance to really "dig deep" and find out what your questions are. I can't really believe that I have been inhabiting this body and mind and soul I guess for nearly 66 years and I still don't really know who or what I am. So, let me start at the beginning, well maybe not that far back but ... 

Names

I guess you all know the story about how Toni Morrison got her name. Toni she decided on herself, after converting to Catholicism at age 12 and naming herself Anthony. Morrison was her husband's name and she was stuck with it because when her first novel was published she was still using it as her legal name even though they were already divorced. There's an quote floating around from 1992 that goes like this: 

"I am really Chloe Anthony Wofford. That’s who I am. I have been writing under this other person’s name. I write some things now as Chloe Wofford, private things. I regret having called myself Toni Morrison when I published my first novel, The Bluest Eye.”

Well, the same kind of thing happened to me. I'd always been Niki, or Nicky when I was very young. Or Nicola when my parents were mad at me. Then in my forties I had a brush with religion - not Catholicism - and I was persuaded to change my name. So I changed it to Rivka, a name I don't even like that much, but who gets to pick their own name. And then my work as a doula, birth companion, teacher, author and my whole birth persona grew wings under the guise of Rivka Cymbalist and there I was, and here I am, just like Toni Morrison (ha!).

So, for now, Niki is reserved for my family and people who knew me before the Great Name Change. But I'm kind of getting tired of inhabiting two separate lives so I may just change my name again.

Bodies

Who knew? Bodies change. I thought the biggest change would be that infamous time when I grew breasts and got my period. Pregnancy was fun. I didn't have such a tough time with it, in fact I enjoyed growing babies. Birthing them was tough, but I really loved having little babies and children around, and breastfeeding, and those body changes didn't really bother me. Some fibroids, a touch of hyperthyroid. Nothing serious. 

Menopause was kind of a relief, no more monumentally Niagara Falls cycles. No more fertility, and I was ready for that, because I was happy with my five children. Did I think I'd overdone it? No.

But then, the thing is, everyone goes on about menopause because it's when a woman is no longer fertile and I guess biologically speaking no longer useful. But the body changes more dramatically and more quickly after the whole menopause thing is history.

I've written about this before, and I have to point out, it's not specific ailments that bother me - thank goodness - I'm healthy. But just like during puberty and adolescence, and I'm imagining anyone with body dysmorphia, I just don't feel right in my skin. Its like my clothes don't fit me right, except they do. My clothes fit, I still take the same size more or less, a medium. But it's my skin that doesn't fit. It feels weird, it's too loose, it's floppy, it doesn't feel like its mine. I look funny in the mirror, who's that old lady? Why is her skin all dry? damn it, why didn't I wear sunscreen for all those years? 

So that's the tunnel I can fall down when I don't remember to center and use moisturizer every morning. Yes, it is my body, yes indeed I am very grateful and proud of it, it's like an old car, just keeps on chugging. But I can't help it, it feels weird.

Profession

Oh goodness, could I just say I'm a witch? I guess not....but this is weird too because I think I studied witchery and magic my whole life, and science too of course. And poetry, and of course I learned all about having kids and all when I went ahead and had five of them. 

But my professional label doesn't exist, because I'm not a registered midwife. I'm a birth companion or whatever. My Impostor Syndrome kicks in frequently; sometimes I think my actual profession is "Impostor".

I've mostly been a mother. 

And the renewal part of this whole exploration? It's a deep, deep sense that change means pain, and from pain comes change. Life just doesn't stop, until it does. So, in a sense, my resting, my recovery, my reflections ... lead to a renewal of sorts which is a kind of an acceptance of the continually changing nature of my life: child, young woman, mother, older woman, mother, older woman, grandmother, mother, birth attendant, peace keeper, rebel, anarchist, runner, crone...

Mothers, Babies, Chaos

Fifteen years ago, I created a ground breaking, unique, stellar doula course with my colleague Lesley Everest. We wrote and taught a ten-month long program that fully prepared doulas to do their important work, with confidence, respect and knowledge.

Part of that course required the students to do some volunteer work with mothers and babies. Two of our students spent a summer accompanying 14 marginalized women through their late pregnancies, labour and birth, and immediate postpartum period. I was away for the summer, as I always am, and I got back to their stories of difficulties and birth, and new families… and so a seed was planted.

That was the summer of 2004. Over the next couple of years, our students continued to volunteer to accompany marginalized families through the childbearing year, and we became recognized by nurses, social workers, dieticians, physicians, midwives, and families as an important resource for those who had, in some cases, literally nothing.

In 2006 Montreal Birth Companions was “officially” born: it was registered as a charity and we were able to apply for funding (even though we never actually received any!). For the next ten years, until 2016, I matched needy mothers with willing doulas. Over the course of its history, MBC served almost 1000 families. Some of them needed a doula to attend the birth of their child. Some needed resources that we couldn’t provide, so we referred them elsewhere. Some needed prenatal education, postpartum assistance, or caring for older children.

I know that now there is a movement amongst the doula community that says loud and clear that for the work to be “valued” it should not be given away for free (that is, for no money). My answer to that is twofold: the first echoes Chance the Rapper “I sing for freedom, not for free”. The second asks who exactly would accompany these mothers if we didn’t? These were people who did not have an extra dollar to their name. They had no money, little clothing, sparse food and crowded shelter.

We served refugees, refugee claimants, women with no status, domestic workers who had been illegally sent away from their employees homes, young women, women from every different country, religion, background, color … the only things they had in common were that they were pregnant and they were poor. We served mothers who had fled war and destruction; mothers who had fled rape and forced prostitution; mothers who were hiding from their violent partners. We served families who just needed help navigating the foreign medical system. We served women who didn’t know how to call emergency services (no, birth is not an emergency, but a haemorrhage is … and do you know how to dial emergency services in Benin?).

And now you may ask, why? Why did we bother? Surely these families were fortunate enough to be able to attend a modern hospital with dedicated professionals to assist them? Yes, absolutely. The women we served were very fortunate to be able to birth in a safe environment. But for women in an already precarious situation, it is so important for them to give birth with as few interventions as possible. For two reasons: first, the less interventions a mother has, the easier it is to recover after childbirth. If life is already challenging, why not give the new mother the best start possible? Secondly, many of the families we were serving, especially after about 2010, did not have access to our provincial health care coverage. This meant that they would have to pay per treatment. The very cheapest hospital birth cost a new family from five to seven thousand dollars. This would be a birth where they only spent 24 hours in the hospital, and the attending physician didn’t charge too much. The most any of our clients owed when she left the hospital was $39,000. We tried our very best to prevent a new family from having to pay for unnecessary treatments. Once we explained to the medical staff what the situation was, we were usually met with understanding and patience.

In 2016, I experienced the consequences of creating an organization with no structure. My joke was always that MBC (Montreal Birth Companions) stood for Mothers, Babies and Chaos. Basically, my mandate was to provide free doula services for mothers in need. That’s what we did, successfully, for many years. But Star Hawk, in one of her books, describes the frailty and danger of an organization that does not have a clear structure: what can happen is that the members of the organization can start to feel threatened, if not by the leader, then by the lack of structure itself.

Two of my doulas were attending the birth of a refugee woman. Only one doula was allowed in the room at one time (the hospital had a rule that only two support people were allowed, and the preacher from the woman’s church decided to attend the birth). The doulas had not previously met the woman; this was an urgent request from the midwives who were following her, and they had not told me that this person would be there.

Over the course of the labour, the preacher harassed the two doulas with sexually intimidating comments, and finally in the morning he physically assaulted one of them. When the doulas told me, I told the midwives and the clinic, and I was met with a strangely layered response: the man had also harassed a nurse at the clinic, and we should be tolerant because he is from another culture where it is common to act like that. 

This bizarre attitude threw me completely, and left me and “my” doulas with no resources except one person outside the organization who tried to facilitate. I felt guilty; the doulas felt angry and shamed, and none of us knew what to do. Why? Simply, because I had not built an organization that contained within it the structures to be able to deal with unforeseen events. Even if you’re an anarchist, even if you don’t believe in Boards, Presidents, and Secretaries, you have to create some kind of structure that can deal with attack.

So what did I do? I stepped down as director and a collective took over the work and the organization. I was so shaken by what had happened I had to leave the work to others. I withdrew, ran my café, and did a lot of running. In December 2016 I was sitting on the bus and I read a tweet by a Syrian journalist about what was happening in Aleppo. I learned that many families had made the dangerous crossing from Turkey to Greece, where they were being housed in camps.

By January 2017 I had packed my bags and headed to Greece to provide midwifery care to the young families in the camps and elsewhere in Greece. It was one of the coldest winters on record. People were housed in UN tents inside abandoned factories. Some of the more vulnerable were moved to apartments and hotels that were vacant and made available. I met with one family from Syria who were being housed in a small room with water literally dripping down the walls, intermittent electricity, and a shared bathroom. She was almost at term, and her baby was breech, and when I suggested some exercise she said it was too painful because of some bomb shrapnel she still had in her hip.

While the larger NGOs argued over bureaucratic details, such as which organization could visit which hotel, I quietly gathered needed resources (clothes, diapers, soap…) from the over-filled basement of the NGO I was working with, and drove to visit pregnant women all over the north of Greece who were in need. I worked with some amazing, brave people and I will never forget that experience.

But then I got back to Montreal and I was met with a deep weariness. I felt that the tiny drop in the huge ocean of need was never going to be enough. I stopped practising as a doula, knowing that there were younger, better, more enthusiastic doulas out there (many of them trained by myself or my colleague). My extensive knowledge of undisturbed, woman-centered childbirth made it difficult for me to witness many of the hospital births I was called to, and my discomfort spread to others around me. I no longer attended home births, as the definition of “practising midwifery without a license” was at the same time clarified and obfuscated by two different legal battles in Canada.

So, where am I? Well, of course, life goes on, so I have a large family to attend to, a successful café to run with middle son, all sorts of projects in the air … and yet … I was made to serve, and I’m looking for another project, so if anyone needs a CPM without papers (let them expire), doula teacher, or a Jill-of-all-trades to work for freedom, I’m in!

Ask the Doula: Evidence-Based Care

It's Ask the Doula time again!

Please keep sending in your questions. You can add them as comments below, or send your questions to our Facebook page, or twitter @montrealdoula.

Today I will be looking at the concept of "Evidence-Based Care". What does it mean? How does it work?

Question Number Four

"What is evidenced based maternity care?"

What is the meaning of life? may be an easier question to answer.

First, I will offer you a collection of attempts to define evidence-based maternity care:

"EBM is about tools, not about rules. Good evidence is likely to come from good systematic reviews of good clinical trials. For many reasons too much of the medical literature can be misleading, or is just plain wrong. We must be able to distinguish good evidence from bad, and to have accurate, reliable knowledge readily available and readily accessible for all. The contrast between the individual and the population as a whole - unique biology, choice and circumstance, often dictates what happens, and evidence is but one part of a complex question."
Bandolier


"Evidence-based care is a type of care in which the medical studies are consulted to help you and your caregiver decide the safety and usefulness of all procedures used. With evidence-based care, only procedures that are proven by research to be safe and beneficial are done routinely. Other procedures which are not supported by the medical evidence are weighed carefully, taking your personal circumstances into account. This is called "informed consent". This may seem obvious, but, for example, routine use of epidurals is not supported by the evidence. 
Birth Matters Virginia


"Evidence based health care takes place when decisions that affect the care of patients are taken with due weight accorded to all valid, relevant information." 
Dr Nicholas Hicks

There is a never-never land that people believe we are heading towards, where our huge glut of information and meta-analyses, and  systematic reviews, and technological advances, will somehow be tamed so that we can quickly pick from any number of studies, the answer to a clinical question that is presenting itself. What is wrong with the picture is that we have become wrapped up in the science, or rather, in the scientific methods (or methods), and we have completely misplaced the person at the center: in our case, the pregnant, laboring, or breastfeeding woman.

I have in front of me an example of the type of study that is being used to support and  maintain evidence-based care. It is an "overview". This means that the researchers looked at reviews of trials. The trials are the actual clinical experiments, which are done on real people in real situations. The reviews are done when researchers look at, for example, ten different trials involving 10,000 women, and compare the results and draw conclusions.


This overview examines at several reviews that looked at pain management in labor. The conclusion is that:

"Most methods of non-pharmacological pain management are non-invasive and appear to be safe for mother and baby, however, their efficacy is unclear, due to limited high quality evidence. In many reviews, only one or two trials provided outcome data for analysis and the overall methodological quality of the trials was low. High quality trials are needed.
There is more evidence to support the efficacy of pharmacological methods, but these have more adverse effects. Thus, epidural analgesia provides effective pain relief but at the cost of increased instrumental vaginal birth.
It remains important to tailor methods used to each woman’s wishes, needs and circumstances, such as anticipated duration of labour, the infant's condition, and any augmentation or induction of labour.
A major challenge in compiling this overview, and the individual systematic reviews on which it is based, has been the variation in use of different process and outcome measures in different trials, particularly assessment of pain and its relief, and effects on the neonate after birth. This made it difficult to pool results from otherwise similar studies, and to derive conclusions from the totality of evidence. Other important outcomes have simply not been assessed in trials; thus, despite concerns for 30 years or more about the effects of maternal opioid administration during labour on subsequent neonatal behaviour and its influence on breastfeeding, only two out of 57 trials of opioids reported breastfeeding as an outcome. We therefore strongly recommend that the outcome measures, agreed through wide consultation for this project, are used in all future trials of methods of pain management." Jones L, Othman M, Dowswell T, Alfirevic Z, Gates S, Newburn M, Jordan S, Lavender T, Neilson JP. Pain management for women in labour: an overview of systematic reviews. Cochrane Database of Systematic Reviews 2012, Issue 3. Art. No.: CD009234. DOI: 10.1002/14651858.CD009234.pub2

So, what have we here? We have a "world where information is replacing the knowledge that displaced wisdom". (Birth Volume 36, Issue 1). We have a huge amount of man- and woman-hours being spent to gather and examine information.This information is considered to be the evidence, upon which we base our standards of care. The authors of this overview have come up with conclusions about the gathering and about the information. Let's look at the conclusions:
1. That the quality of the evidence-gathering was low, for various reasons.
2. Non-pharmacological methods of pain relief appear to be safe but may not work.
3. The effects of pharmacological pain relief on the baby has not been assessed.

From these conclusions, we can see that the researchers seem to have the best interest of mother and baby at heart. They want more studies on non-pharmacological methods of pain relief, and we get the feeling that they would like those studies to prove that these methods work. They want more studies to be done on the effects of maternal pain medications on the newborn, on breastfeeding and beyond, and we get the feeling that they would like these studies to lead to a decrease in use of pain medication,.

But it seems to me that here we are running into the late Phil Hall's suggestion that  "after initial gains in evidence-based medicine, we have moved from evidence-based decision-making to decision-based
evidence-making." (Birth Volume 36, Issue 1)
Make the decision that you would like to promote a more humane type of maternity care in your practice. Look at the studies that may support your hunches about how this can be facilitated. Draw your conclusions, make some protocol changes, and bingo!

The problem is thought, that studies can be deeply flawed and they can still be taken seriously. Let's go further with our overview:

It remains important to tailor methods used to each woman’s wishes, needs and circumstances, such as anticipated duration of labour, the infant's condition, and any augmentation or induction of labour.

What is this supposed to mean? I would say it is absolutely important to place the woman at the center of the whole event, where she belongs. Go as far as you can to fulfill her wishes. Cater to every one of her needs. But as soon as we start tailoring methods to a woman's circumstances, we get into trouble. Anticipated duration of labor, we all know, can often be wrong (is there a study?). The infant's condition of course is paramount, but are we then getting into continuous fetal monitoring? And are the authors suggesting that a woman should take an epidural before an oxytocin induction? (I'm not being facetious, it is offered frequently).

What's the biggest problem with this picture?  The whole overview completely missed out on one very important part of the equation. They mentioned massage, aromatherapy, sterile waters injections, TENS, and other methods as non-pharmacological, but nowhere in the overview does anyone mention the benefits of having one continuous presence - a companion, not the partner, but a companion who is trained to accompany women throughout labor and birth.

Let's take a look at the reality. Even during a traumatic, painful labor and an unexpected outcome, women feel better about their birth experience if they have been lucky enough to have had the presence of a doula. And isn't a positive experience for the new family what we are all trying to achieve?

The evidence is right there. You don't need to study or review. Just open your eyes, and then take the giant leap of trying to change practices and protocols.