MAYD to Birth: At Your Doorstep

Promoting gentle, empowering mother journies…

Genette in San Francisco!

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Well, all I can say is that we have been on the go! I keep asking Genette if she is tired and she keeps saying no, so we just keep rolling right along! On her first day, we went to our local Peer Review meeting and spent the morning listening to cases. Genette found it really interesting and said it was a good experience for her.

In the afternoon, we did a little introduction of San Francisco. We went to Dina’s television station (could that not be more different than life in Hinche?), we found a local food festival where Genette tried everything from gourmet chocolates to cheeses to fish tacos to kamboucha!
 
We visited my daughter’s school, met up with Jenni from MANA who nominated Genette for the award, and explained to Genette that she would receive the Sapling award at the conference. I’m not sure if she understands how important it is, but she’ll know at the conference.

On Saturday, we had a welcome brunch for Genette and invited some of the donors, local midwives and clients of mine that are so excited she is here. Genette had crepes for the first time and really liked the sweet crepe with pumpkin butter! In the afternoon, we watched my daughter’s volleyball game, went to the Pacific ocean

 and finally, a birthday party for a friend of mine that included a “variety show!” She saw tap dancing, a woman playing saxophone, an opera singer, and lots of others. We got up and sang both Dina’s “Kijan ou ye” song and one of the Matron songs. I explained what they meant to my friends (about 50 people were there) and they all felt that it was meaningful and powerful to hear what the songs meant and that Genette was here with us.


So, it hasn’t just been playing! On Sunday, we went to Elizabeth Davis’ midwifery class. I teach phlebotomy and speak on a panel of midwives about our lives as midwives. Genette helped out with the observations of the students trying the phlebotomy and during lunch we spoke about the Midwives for Haiti program. She was on the panel with us and the students really enjoyed hearing her bio and asking her questions.


Monday morning was an observation day at my local hospital with an OB friend of mine. We are all faring well in Creole, and we are pushing Genette to practice more of her English. She understands a lot.
All in all, we are having a ball! We leave for the conference tomorrow. We have been so busy that I have had little time to post. I will update you with more later.

Birth is empowering!

tears or near tears

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last year (or approximately) we started trying to get the kids up to date on their vaccines. augustine got some when he was a baby, but selectively and olive didn’t have any until after 2 or 3. oh you think you’ll remember and keep all of these Super Important Details of your kids life cemented in your brain but really, you won’t at all! they will get filed away and you’ll wonder what the whole freaking hoopla was all about. do your research, find your path, and don’t be afraid to dig your heels in OR know when to give up a fight even if it makes you feel like an idiot for being so passionate about it at one time. i’m still not budging on the hepatitis shots. ANYWAY as of thursday augustine is all caught up (except aforementioned naturally) and oh guys it was hell!

with most hard choices comes a trade off and holy crap am i getting what i paid for by delaying. meaning the kid is old enough to freak out but not old enough to show a lot of self control about his fears. so let me set the scene before i keep rolling with this. i’m sitting in the waiting room and from behind one of the doors comes the unmistakable peeling of a baby getting circumcised. i’m talking SHRIEKING, WAILING, pissed off baby screams. so my stomach is already reeling from that noise. a few minutes later the mother, holding little, angry infant walks out of the room freaking out, crying, pacing, and flees to the parking lot. so baby is crying, mom is crying, receptionist is paging a nurse to come assist them to calm down, the nurse from their room is running out to the parking lot, the dad is looking helpless. i mean this sounds like this family is having the worst day ever.

i am not kidding you when i say this baby screamed for the entire freaking hour we were there. the peel of a baby screaming is a unique torture let me tell you. so i have my children plus a girl i babysit after school with us. i am all wound up and stomach sick from the baby screams by the time we get back to the room. after a short discussion, update to the kids stats, it’s go-time for shots. olive LAUGHS the whole time and goes first. augustine meanwhile has backed himself into the corner yelling, crying, and digging his feet into to ground so i am having to physically heft him onto the table. this after a 5 minute discussion about how he has control here. “do you want to sit or lie down?”, “do you want the shots in the leg or arm?”, “which shot goes where?” etc. nope the answer to everything was NOOOO!!!. so i heft my 50 lbs 7 yr old onto the table and have to hold him down while he bicycle kicks for his life all the while a newborn is shrieking through the wall and i’m babysitting AND I NEED TO GET OUT OF HERE NOW.

eventually we get out of there and we’re all exhausted, sweaty, and tears or near tears. well except olive who honey badgered the whole thing.

Early Labour and Mixed Messages

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Artwork by Amanda Greavette: http://www.amandagreavette.com

This post is about early labour and the mixed messages women are given about this important part of the birthing process.

Defining the indefinable

The concept of ‘early’ or ‘latent’ labour emerged as a result of the birth process being broken down into stage and phases – the diagnosis of which relies on clinical assessments of contraction pattern and cervical dilatation. The notion of being able to determine the future progress of labour from such clinical assessments is not supported by research, yet it underpins maternity care. What research does show is that concepts of stages and phases of labour does not align with women’s perception and assessment of their own birth process (Gross et al. 2009; Low & Moffat 2006; Dixon et al. 2012).

In addition ‘early’ is only ‘early’ with hindsight. At one point in time (the clinical diagnosis of early labour) there is no way of knowing if labour will result in a baby in 30 minutes or 24 hours. If a labour is 2 hours long… when did early labour occur? As previously discussed an individual woman’s body is unique and so is her labour pattern.

Labour is basically the process by which a baby moves from the inside of a woman to the outside of a woman. Sounds simple, but it is incredibly complex and involves a complicated interplay of physiological, psychological and emotional factors. Women’s experience of labour often involves a sense of separation from the external world, focussing within, and becoming immersed in the act of giving birth. The hormones released during birth support this ‘altered state of consciousness’ (see the work of Sarah Buckley). During early labour the woman is beginning to move into this birthing state. Many midwives, including myself use the changes in behaviour displayed by women as they move into, and through the ‘birthing state’ to estimate how close the birth is. Of course, just like clinical assessments this is not entirely reliable as some women do not follow the usual scenario.

Despite the fact that concepts such as ‘early labour’ and ‘established labour’ are constructed, and not very helpful… I need to use these terms in this post because they are used consistently in the literature I am discussing (apologies).

Hospital perspective: early labourers are not welcome

Women admitted to hospital in early labour are more likely to end up experiencing complications and interventions, including caesarean section (Klein et al. 2004; Bailit et al. 2009; Rahnama et al. 2006). There are two explanations for this:

  1. That these women already have a dysfunctional, prolonged labour which is why they are coming to hospital in early labour. This explanation is favoured by a local hospital, and their response is to augment (ARM and IV syntocinon) all women who are admitted in early labour who do not establish labour within 2 hours. The rationale is to avoid a prolonged, complicated labour… and according to the obstetrician ‘women don’t want to be in labour for a long time’. I wonder if the women are consenting to these procedures based on adequate information… or just being asked if they want a shorter labour (hands up!)
  2. That exposure to the routine interventions involved with care in a hospital setting increase the chance of complications occurring (Bailit et al. 2009) ie. the longer the woman is in the system, the more opportunity there is to ‘do stuff’ to her.

Women admitted to hospital in early labour also cost the institution more money because they are on the ward for longer which increases demands on services and staffing. Therefore, great efforts are made to deter women from settling themselves into hospital during early labour. Antenatal classes warn women to stay away from the hospital for as long as possible to avoid intervention. When women ring hospital to enquire about coming in they are advised to ”take a paracetamol, have a bath the ring back in an hour” (guilty). Women are also told to only come to hospital when their contractions are coming every 5 minutes or less – which is concerning because the pattern of contractions is not necessarily an indicator of when the baby will be born. Entire services have been devised (phone support/home visits) to support women to stay at home during early labour (Janssen et al. 2009). When women arrive at hospital they are subjected to invasive clinical assessments to diagnose ‘established labour’ before they are ‘cleared’ for admission to labour ward (Cheyne et al. 2008).

If a woman does manage to get admitted whilst in early labour she is considered a burden by staff. She is likely to be put in a room and checked on occasionally and referred to as ‘not doing anything’, ‘niggling’, ‘she should go home’, etc. The midwife who admits her will be questioned and ridiculed at handover. The midwife allocated to her will most likely also be caring for a woman in ‘real labour’, and that woman will take priority. This is not to bag hospital midwives… I’ve been there myself, and it is very frustrating dealing with a woman in early labour whilst also caring for 1 or more women in ‘advanced’ labour. Whilst not condoning the hospital perspective on early labour – I can understand it from a cost/staffing perspective.

Women’s perspective: seeking reassurance and safety

Findings from qualitative studies suggest that staying away from hospital during early labour can be challenging for women. It seems that women want to be in hospital. And the experience of being assessed as ‘not in labour’ and sent home can be distressing and result in women feeling unsupported (Baxter 2007; Barnett et al. 2008; Scotland et al. 2011). A study of first time mothers found that women experienced embarrassment when they arrived at hospital too early to stay (Eri et al. 2010). They also felt vulnerable when negotiating with midwives to stay. The need to be in hospital is not necessarily about needing pain relief or support. Cheyne et al. (2007) found that women wanted to be in hospital during early labour despite feeling that they were coping well at home. Some participants reported feeling uncertainty about the safety of their baby whilst at home. Carlsson et al. (2009) also found that women were concerned for the wellbeing of themselves and their baby whilst labouring at home. They identified the theme ‘handing over responsibility’ as the core category emerging from their data. Women were keen to transfer to hospital in order to hand over the responsibility for safety to midwives.

Another concern associated with staying at home during early labour is uncertainty about identifying when established labour begins. Women in Cheyne et al.’s (2007) study expressed concern about not knowing how advanced their labour was while at home. Beebe et al. (2006) also found that first time mothers struggled to identify the onset of active labour themselves. Women worried about going to hospital too soon or too late, and were unsure of how to know if their labour was ‘the real thing’. Their main concern about staying at home was not being able to have their labour assessed by hospital staff. In Eri et al.’s (2010) study women perceived midwives as ‘gatekeepers’ with whom they had to negotiate their credibility with in order to gain access to the hospital. Gross et al. (2009) found that women’s own assessment of how and when their labour began was varied and did not match midwives’ clinical diagnosis of labour onset. A study of first time mothers by Low and Moffat (2006) found that women were perceived as abnormal by hospital staff if their experience of labour onset did not fit clinical definitions. Themes identified from the data included ‘this is not right’ and ‘don’t trust your body, trust us’

Physiology and contradictory messages

Let’s take a look at physiological explanations for early labour behaviour. Like all other mammals, labouring women seek a private and safe place where they can avoid distraction and immerse themselves in the act of birthing. During early labour women seek a place to settle and ‘nest’. This makes perfect sense because the neocortex is still engaged and can slow contractions (by reducing oxytocin) in response to thinking, talking, etc. - the woman can think clearly and do the practical things involved in a physical move. Once the woman is settled and her neocortex is not being stimulated, increased oxytocin release re-establishes contractions. This explains why labour often slows down in response to the move to hospital. However, as labour progresses the limbic system takes over and it becomes more difficult – and dangerous from an evolutionary perspective – to move from place to place. The neocortex is suppressed and the woman is deeply in an altered state of consciousness. This is the women who arrives at hospital already ‘separated’ from the external world, nothing stops her contractions, and she is often unaware of those around her until after the birth. So, the need to settle into the birth place during early labour is a normal response to the physiology of the birth process. It is also common for women to call on the support of other women during labour – women they know and who they feel safe with – relatives, friends, midwives, doulas. Early labour is a woman’s signal to get settled somewhere safe and to gather her ‘women-folk’ around her.

What is considered a ‘safe place’ is influenced by the culture in which the birth is taking place. I am not getting into the debate of hospital vs home re. safety. One, because I am totally over it, and two because I am a slightly biased homebirth midwife. Here is a Cochrane Review if you feel the need to head into the debate. Women in Australia (and many other parts of the world) are urged to birth in hospital because the cultural concepts of ‘safe’ involve medicine and technology. The experts in birth are the people who know how to use the medicine and technology, and who can carry out clinical assessments to determine wellness and progress (Davis-Floyd 2003). This message begins in pregnancy as women undergo routine clinical assessments with an emphasis on professional experts providing reassurance of wellbeing. Women are also bombarded with fear-based media about the dangers of birth, and the hospital-based Knights in Shining Armour who will gladly rescue any Damsel in Distress (and her baby). Therefore, it is not surprising that women head for the safety of the hospital when they are in early labour. Our culture has replaced the home/birth hut + well known women-folk with the hospital + unknown medical staff.

The emphasis on hospital as a place of safety whilst also encouraging women to stay away results in some very contradictory messages and ideas (please note these statements do not represent my own views):

  • We are the experts in your labour progress, only our clinical assessments can determine what is happening… but we’d rather you do not come in to be assessed, and instead stay at home not knowing what is going on.
  • Trust us – we want you to have a good birth experience… but if you come in too early we are likely to create complications which will require intervention… so keep away from us as long as you can.
  • We are the experts in your labour progress, our clinical assessments can predict your future labour progress… we will send you home if you are found to be in early labour… if you then birth your baby in the car park it is not our fault as birth is unpredictable.
  • This is a safe place to labour…. but you can only access this safety when you reach a particular point in your labour… preferably close to the end of your labour i.e. you should do most of it on your own away from safety. This contradiction results in a very annoying double standard: A women who labours at home and comes into hospital ‘fully and pushing’ is praised – ‘she did a great job’. However, she laboured (perhaps for many hours) without the attendance of a professional and without any monitoring (eg. fetal heart rate auscultation, etc.)…. On the other hand, a woman who homebirths intentionally is considered to be doing something unsafe despite the constant attendance and monitoring of her midwife.

Suggestions

Rather than considering ‘how to prevent women in early labour being admitted to hospital’, instead it may be better to explore how women’s needs during early labour can be accommodated by the maternity system. I would be interested to know what your experiences and/or suggestions are. Here are some thoughts, as usual I’m ignoring constraints of the system and money in favour of fantasy:

  • Antenatal care should centre on building self trust and reinforcing the woman’s own expertise in birthing her baby. If she relies on herself to determine wellbeing and progress she may be less likely to head to hospital early for reassurance. A study by Carlsson et al. (2012) found that first time mothers who managed to remain at home during early labour expressed a sense of power. Maintaining power was the central focus for these women and involved a sense of authority over their own body. Something to be encouraged I think!
  • Give early labour respect. It is an important part of the birth process and women deserve recognition for it… ie. don’t use the term ‘latent’ or ‘not in established labour’. The woman has begun the birth process. She has her signal to seek a safe place – help her do this.
  • Women’s access to their birth space should not rely on them meeting arbitrary measurements which involve invasive clinical assessments. They should be able to use early labour to get to their ‘safe place’ and settle for birth.
  • If you are planning to head to hospital while deeply in the altered state of labour – it might be useful to take along a doula who can advocate and use her neocortex while yours is suppressed.

Of course if a woman is birthing at home with a known and trusted care provider it is a different kettle of fish. She doesn’t need to concern herself with ‘when to go to hospital’ – and her care provider can (should) attend based on when the woman needs her…  not when she meets particular criteria. Then again in the real world not all women want to birth at home, or can get the support to do so. Therefore, the systems in which they birth need to change. The essential problem is that maternity care has developed in response to the needs of institutions – not the needs of women. More research is being done… and reports published about what women want from their maternity system. Unfortunately what they want (woman-centred, continuity of care) is the opposite to what is already deeply embedded in our society (hospital-based, fragmented care). To turn this around is a huge undertaking… and change will undoubtedly meet resistance from those who benefit from the way things are.

Disappointed in Mixed Messages

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There is a new marketing campaign for safer car seat use in the US. I’m so glad that we have this type of information going out to parents, because it’s honestly a huge problem. (About 80% of parents misuse their car seats.) My problem is not with the campaign, but with one of the ads used in the campaign, seen above. Given all the money and time that goes into the government’s breastfeeding campaigns, I’d love to see them have a breastfeeding in all policies approach and be sure to exclude bottles from gratuitous use. If this were a campaign about how to properly bottle feed, I’d have zero complaints. But using a baby bottle as a simple graphical design undermines breastfeeding. The contact information that they have listed is as follows:

“For additional child safety campaign information, contact NHTSA @ 202-366-3587 or elizabeth.graziosi@dot.gov

Though I’d also like to say that perhaps we also need to ask the Ad Council to stop using baby bottles to represent all things baby.

To contact the AdCouncil @ 800-933-7727 or AdCouncil@ci-groupusa.com

 

Yes, You are in the right place!

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We have a new look at the office. When you walk in, “Yes, you are in the right place!” (Thank you, Denise Dinocola for taking this great photo and a few others. Check out more of her photography.) Some are my snapshots (They are easy to identify).

This is the sign you see when you walk in. I truly believe in trusting your instincts.

I thought David, my son, was going to stay all day and play. He was fascinated with old fashioned games.

David thought the playground built by Crystal and Amber was for 8 years and under. (He just turned 9.) TTT and HS is for “my age.”

If you want to know why the room was updated, Here is something to help you remember the old seating.

The ugly fountains are gone. Hopefully more great changes to come!!!! Thanks to everyone who had ideas and moved these ideas forward.

Permission to Mother now available on Kindle!

Catching up from summer

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Wind turbines
- we went on a vacation. it was fun and silly and oddly a good mix of relaxing and mega-fun-time. we hit up a lot of my childhood haunts and i got lots of delicious cheese (one even had bacon IN the cheese!!!) it was a good mix of nostalgia and memory making. here’s some pictures of us in wisconsin
All you can eat? Challenge accepted
Family chow
In a teepee
Happiest place on earth!
Little Indian scouts more cheese this way
Cookie dough shake

Long time no post!

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augustine is now in second grade, and olive started kindergarten! justlikethat my babes are further out of the nest. this time during the day has afforded me much coveted quiet time to work. i’ve been working from home since olive was an infant and i kept reminding myself when it felt overwhelming that someday, SOMEDAY it would get normalize when they would go to school. well, someday is now! i have yet to find a daily routine but i quickly realize that i am a morning person (surprising to me!) as far as production go. from the hours of 8-noon i can get as much done as the rest of the hours of the day combined. so i feverishly work on reports while the dishes are soaking or laundry is running or muffins are baking and post-lunch i start getting distracted, sluggish, and bored with work and it takes a lot of effort to stay on task.

me aside, the kids are thriving in school. the first day went almost seamlessly. augustine’s gifted program officially started this week with a mini course in physics and aero dynamics. he was excited to get hopping. olive has TWO boys fight for her affection and those two boys have yet to find a place where they work together as a trio and are not constantly pulling for her undivided attention. what first world problems eh?


“mom i think henry likes me.”
how do you know if a boy likes you?
“because he kissed me right on the mouth!”

well that settled it. david went into full DADDY MODE and took her on her first date, complete with dressing up and presenting her with a flower when he “picked her up.” too freaking cute. she put on her favorite dress and they went to dinner and a movie. gosh i love that man.

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the children had their first soccer game and i think olive is going to be an amazing goalie. she had 5 stops, though no one scored on either kid.

in conclusion, FALL IS ALMOST HERE.

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Handy Tips to Remember the Ten Steps to Baby Friendly

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Have you seen the new Luvs Commercial?

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Genette to come to the US for MANA conference!

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I am so excited to say that Genette got her visa on Tuesday! I really think the efforts at the embassy and some critical emails to the embassy really made a difference. She is the first midwife from the Midwives for Haiti program that has successfully acquired a visa to come to the US. One of the criteria that the US embassy looks at to consider granting a visa is a person’s salary. Now, of course, the Haitian midwife salaries are nothing like US salaries. Genette makes $6000 per year. This is not to her advantage in trying to come to the US. The embassy looks at this as a sign that she might see how much more she can make in the US and attempt to stay. I am sure that this is why Esther’s visa application was rejected. In my emails to the embassy, I emphasized Genette’s commitment and dedication to midwifery in Haiti. She is so deserving of this continuing education opportunity.

I think that this will be a significant step in developing Genette’s leadership potential. She is already hired as the Clinical Director of the Midwives for Haiti program and is one of the main leaders of the Matron program. Along with Magdala, Dina calls them the power couple. They developed the Matron program which is a 20 week education program for traditional birth attendants in the small village of Haiti where still the majority of babies are being born. You can see what a difference Magdala and Genette are making in terms of education, empowerment and continuity in the Midwives for Haiti program. By bringing Genette to the US, I am hoping that she will be able to expand her vision of midwifery-learning skills and concepts through the conference and in San Francisco.

If you would like to help fund Genette’s trip, please send checks to my address: Maria Iorillo, 206 27th St. San Francisco, CA 94131. Write your check out to Midwives for Haiti and put Genette Thelusmond in the memo line. Thanks!!

Birth is empowering!