Home » News » News

Category: News

The Missing Element in Addressing Obstetric Violence

Obstetric violence is a global phenomenon. Nowhere is it more frequently observed and recorded than in South Africa. It is a violation of human rights that requires urgent attention.

Suggested remedies range from punitive measures to teaching the perpetrators (in the workplace this is usually the midwives, as obstetricians are mistakenly presumed to know this already) how to treat women in labour well.

The interventions are not making a deep enough impression. Midwives report that they are just one more item of requirements on a back-breaking to-do list. Abuse remains unabated. Drastic measures are called for. And the most drastic measure is the recognition that the missing element in the equation is love.

On a continuum of love, with unconditional love placed on one end, it is not hate that we find on the other, but fear. Love versus fear. We live in a fear based society, and nowhere is this more prevalent than in maternity.

Mothers are terrified of pain. To let go of pain they need to let go of fear. To let go of fear they need love and support.

Midwives are afraid of retribution for mistakes made. They hold fiercely onto control. The control of ordering women around and of seeing efficiency as the gold standard of maternity care. While efficiency is important in busy hospital wards, it happens at the expense of feeling. To let go of this control and the fear that drives it, the midwives need love and appreciation for the wonderful work they are doing.

Obstetricians hold the final responsibility for maternal and neonatal outcomes on their shifts and in their wards. It is natural for them to be afraid of mistakes and poor outcomes. Birth can be dangerous, and obstetricians have to pay the highest insurance premiums of all doctors for malpractice because things do go wrong at birth. Nobody wants our mothers or babies to die. Once again the response to this fear is one of looking for ways to maintain control. The best way to control labour is to intervene with inductions, vacuum extractions and caesarean sections, even though evidence shows that overuse of interventions leads to negative outcomes. Interventions reduce fear though, so their use continues to rise unabated. Once again, the best way to let go of this fear is through love.

All care providers in maternity, including the obstetricians, need to be respected, listened to and loved enough to allay fear that is deep seated and suppressed under layers of control and years of training to put their own feelings aside. This fear is often not even recognized until it is squarely faced. Like racism, religious intolerance and gender discrimination, the fear at the heart of maternity is an unconscious shadow. It is the pervasive and underlying demon at the heart of obstetric violence.

When did we lose the sacred, awe-inspiring love that is the birthright of every baby? If we bring joy and love back to the birthplace for both the perpetrators and the victims of this violence, then and only then do we have a real chance to slay the monster of fear.

Balancing the Power in the Maternity system.

I find it hard to work in hospital maternity wards. In the South African private sector, the majority of obstetricians who are in charge of all the deliveries, not ‘births’ but ‘deliveries’, are autocratic in their decisions to ‘cut’ (doctor speak for perform a caesarean), vacuum, slice episiotomies or to induce their patients. Not ‘clients’ of course, but ‘patients’. There is little consultation or discussion, the patients are told, jovially, because they’re paying, that doctor knows best, and that they’re exceptionally fortunate to have a healthy baby. We all know that scenario.

In the public sector, where the births are also referred to as deliveries but are overseen by midwives, the lack of parental autonomy is even more pronounced. ‘Patients’ are seldom greeted by name, and abuse ranges from patients are being slapped across the face in labour, yelled at that they will kill their babies if they don’t behave, punished by being left on their own to birth their babies, or told to clean up their own ‘mess’ after giving birth.

My initial reaction is inflammatory. The balance of power must be addressed, the victims of the system need my help. We, who know better, should rise up and address these issues with sirens blaring, guns firing on semi-automatic and grenades exploding. David and Goliath stuff. Except that Goliath wins almost every time.

Albert Einstein, bless him for his wisdom, said ‘No problem can be solved by the same level of consciousness that created it’.

I need to draw far enough away from the situation that my incendiary reactions are not sparked by what close up can only be termed obstetric violence. From a distance I see victims and perpetrators caught in an unhealthy power dynamic in an over mechanized system that dehumanizes everybody, ‘patient’ and doctor alike.

You can’t have a rapist without a victim of rape, a bully without someone more vulnerable to abuse, a dictator without an oppressed populace. They feed one another. The midwives who are abusive to laboring women pick the most vulnerable women to be mean to; the teenagers, the refugees, the HIV positive women, the sex workers. For all that these women might be screaming or whimpering in pain in labour, they are voiceless victims in the system.

If I look deeply into the continuum of power, an interesting pattern around masculine and feminine archetypes emerges. These are not gender classifications. I know plenty of aggressive women and many wimpy men. In Chinese medicine the archetypes would be referred to as yang and yin. In the West the archetypes are probably clearer in their masculine and feminine forms. On a continuum of power from the extreme exploitation of the tyrant through balanced equity of power down to the total disempowerment of the victim, the negative masculine energy holds the most power and the negative feminine energy holds the least. Positive masculine and positive feminine qualities sit balanced in the center.

Power traits

Negative Masculine

Positive Masculine

Balance of power

Positive Feminine

Negative Feminine

Abusive

Dictatorial

Tyrannical

Raping

Killing

Autocratic

Closed hearted

Judgmental

Wise

Providing

Protecting

Intellectual

Rational

Grounded

Warrior energy

Benevolent

Transcends emotions

Standing in Truth

Integrity

Authenticity

Equanimous

Respected

Respectful

Loving

Maternal

Nurturing

Tender

Abundant

Fertile

Peaceful

Listening

Serene

Intuitive

Victimized

Manipulative

Secretive yet Gossiping

Scheming

Martyr complex

Helpless

Pained

Vulnerable

Victims and abusers feed one another within this dynamic. By fighting for the oppressed, or trying to torch the system, the problem doesn’t go away, the dynamic remains the same. We have simply switched sides. We are still caught in a negative feedback loop where nobody is happy.

Unequal distribution of power is killing our planet through plunder and extinction of species and greed for more power. It is also killing the heart of the maternity system, because it is so hard to stay open hearted in the midst of so much fear and passive aggression.

What would Albert Einstein, Nelson Mandela, Ghandi, Martin Luther King or Aung San Suu Kyi do?

They would step out of the oppressor/oppressed loop and stand in their own balanced power in the center. Nelson Mandela was considered a fool to engage in dialogue with the Afrikaners and British Colonialists, who were responsible, either through their actions, or through their ignorant disdain, for imprisoning him for twenty-seven years for challenging the Apartheid regime. After his release, he didn’t trust that what they had done to him was acceptable or good; he simply trusted in the underlying goodness of their souls, beneath the fear that caused them to incarcerate him for all those years. He said, “The best weapon is to sit down and talk.” Our response to his trust was a global, unanimous love for the man. He imagined the best in his oppressors and brought out the best in them.

A centered place of power is a place of wisdom, truth, authenticity and clarity, but it is also a place of love and the ability to listen deeply to everybody.

If we think that it is only the women who are being slapped in labour who are in pain, we are caught in judgment and are not yet looking deeply enough. The midwives who are yelling at them are in pain too. No-one listens to them, they are undervalued, overwhelmed, emotionally overloaded and burnt out.

If we think that the obstetricians who don’t recognize the emotional needs of patients and infants are too focused on golf or on the latest technological gadget, we need to look deeper. They have insurance premiums that require that they attend a minimum of thirty births a month if they are to survive financially. Try doing that without a few cesareans a week! And in too many academic institutions worldwide, the hearts of medical students are forced closed during their training, as an unspoken part of the curriculum. They are taught that they have to hold it together at all costs and never show their feelings. They are taught to become authoritative and to give the impression of knowing it all, under the mistaken illusion that this will make patients feel safe. It is a lonely, often frightening place to be, where there is no debriefing and no skills training in compassionate care for themselves or their clients. They too need to be heard, they too want a better world for everybody. They too, hurt deeply under their masks when their patients are in pain or the midwives are abusive.

The doctors might think that a better world is one where they have more technology, the midwives might think that a better world is one where they have more power than their peers and can become like the doctors, the patients might think that a better world is one where they never have to see that midwife again and where they can seek retribution for their violent birth experience. All those things matter and are good. They need to be taken seriously.

But they will not change the system.

Let’s move into the center of our power. Let’s become like Mandela. Let’s be wise and listen to all sides of the story with equal interest and empathy. We are all in pain, and we all need love.

by Robyn Sheldon

The changing paradigm of birth in the public sector in South Africa

“An invasion of armies can be resisted, but not an idea whose time has come.”

Victor Hugo

Projects, research, reports, policies, training programs and social media support groups invested in supporting an “idea whose time has come” are burgeoning in the public maternity sector in South Africa. The idea is timely and in response to a crisis of maternal abuse in labor by medical staff that has reached epidemic proportions and is widely researched (Jewkes, Abrahams and Mvo 1998). Horrifying articles have emerged, such as the 2011 Human Rights Watch report, “Stop Making Excuses” (2011), which writes about mothers’ experiences in labor in clinics in the Eastern Cape, a very poor province in South Africa.

Abeba M. states in the Human Rights Watch article,

A lady and her baby died in our ward. I did not think I would survive. Later, another woman suffering from high blood pressure also died. I thought I was next. I was so sick. I had blurred vision. When the second lady died, the nurse asked me, “Oh, you are still alive?” and the doctor said, “That lady is dead? Who is next?”

I was suffering the whole night and I was calling the nurses and they did not come. I remember it was on a Sunday. The nurse I was calling was playing a gospel song on her cell phone and dancing. I told her I was feeling very sick. She said, “I know, and what do you want me to do?” She was walking up and down whistling and dancing. (Human Rights Watch 2011, 22)

Of course there are wonderful midwives as well; most South African midwives are empathic and caring. However, the system doesn’t always support them to be so. In their 2012 World Report, Human Rights Watch stated, “The government’s failure to provide effective oversight for the implementation of existing reproductive and sexual health-related laws and policies contributes to South Africa’s high and increasing maternal death rate, as does a lack of accountability for recurrent problems in the health system, including abuses committed by health personnel” (2012, 168).

The reports on maternity staff abusing patients have created a culture of shame amongst midwives, who are understandably defensive in response. However, the hierarchy in the medical establishments remains mostly unchallenged. In the public South African hospitals, there is little place for questioning, negligible space to be listened to and not enough recognition of the need for airing of grievances. The life of a midwife is hard. Many nursing staff live far from their work place in the urban areas, and public transport is both expensive and unsafe. Too many nurses in South Africa head up households and are the breadwinners, often to unemployed extended families. The unemployment rates are extremely high. Young, strong, beautiful men, who have no chance of ever getting a job, take to crime and alcohol or drugs to relieve the feeling of being thwarted at every turn. This creates a lack of worth so disempowering that these men sometimes take their frustration out on the women, and both domestic violence and sexual abuse are endemic. These same women who experience such hardship at home come to work where the stressors in the maternity wards are intense. They work twelve-hour shifts. There are too many women in labor and too few staff on duty per shift. The laboring women are often alone, have had little or no antenatal education and are terrified of the midwives and the authoritarian attitude in the clinics. As a result of their high levels of fear, they are in extreme pain and behave “badly,” and in consequence are subject to slapping. They are often reprimanded with statements such as, “If you don’t stop that, you will kill your baby,” or they are told to clean up their own mess and are made to wait in punishment for “bad” behavior.

Right now in South Africa, there is a groundswell response to the critically high stress levels in our maternity wards. It is a movement, a collaboration, an emergence of hope and vitality and a belief that perhaps we can really change the system. Like raindrops spattering into a pool of water, groups of people are creating concentric circles of influence that are radiating outwards and intersecting with other groups to create a network of promise for a different way.

Ruth Ehrhardt, a midwife, is a team member of the Compassionate Birth Project. She says, “I feel like I am no longer swimming against the stream, but that there is enough support around me that I am flowing with the stream these days.” The Compassionate Birth Project comprises of a three day retreat and a follow up 12 week program of one and a half hours per week per clinic, where midwives are given the opportunity to experience deep listening and learn listening skills, to apply this to solution oriented debriefing, to receive massage and be taught basic massage techniques, to learn relaxation, to dance, sing, and appreciate and value themselves and one another and lastly to be given time for silence and time to simply enjoy themselves.

Professor Lynette Denny heads the Obstetric Department at the University of Cape Town Medical School. Even amongst the top echelons of the Ministry of Health, she is a highly respected voice, demanding better birth practices and a recognition of women’s rights. Alongside numerous other research projects and studies, Lynette set up tutorials on compassion for her fourth and fifth year medical students, envisioned the initial concept for the Compassionate Birth Project and was the catalyst for the Patient-Centered Maternity Care Code of Conduct which has been ratified by the Department of Health. This is seen as a step towards addressing South Africa’s inability to meet their maternal child health care targets as stipulated by the Millennium Development Goals for 2015. The Western Cape Department of Health has committed itself to patient-centered care as a fundamental principle for its draft 2020 strategy.

Dr. Nils Bergman, a world authority on skin-to-skin contact, has a vision to create a birth facility designed on neuroscience, where women in the public sector have access to skilled and compassionate care. His project intersects with the Compassionate Birth Project, with the plan to up-skill midwives, doctors and student midwives by exposing them, one or two at a time, to best birth practices in this clinic. Nils says, “We need to re-create a standard for what is a normal birth: not one based on a disease orientation and adverse outcome avoidance. The key is to ensure the mother feels safe, supporting oxytocin and the reproductive neuroscience linked to this” (Bergman, personal communication).

Zinzile Seepie, who runs the Zulu Birth Project, is collaborating with the Compassionate Birth Project to devise doula-training programs that can be rolled out nationwide. She says, “If African women in all their glory, forms and kinds can be supported through birth in a dignified, conscious and empowering manner, many of the social ills witnessed in South Africa will become a distant memory. When women birth in terror, their parenting is affected, their relationships with their children are affected. However, the opposite is also true! Women who are compassionately supported and loved through pregnancy, labor, birth and postpartum are reminded that they are precious, honored and worthy of love. This is echoed in their relationship with their babies” (Seepie, personal communication).

The annual Midwifery and Birth Conference provides a melting pot for the exchange of exciting ideas for midwives. In the past, the majority of attendees have been independent midwives and doulas. Now midwives from the public sector are clamoring to attend, too. They are waking up to the idea that there is support out there and that birth work doesn’t need to be so arduous. They are finding out about this conference, and the upcoming Human Rights Conference, and about changing the way they work through social media support groups, such as Empowering Midwives of South Africa, Young Midwives of South Africa and African Midwives.

These social media platforms are also offering a crucial form of support for young midwives, who after six months of midwifery training are sometimes sent to rural clinics where they often find themselves as the only midwife on duty. On occasion they have to deal with complicated obstetric emergencies on their own. At least these days they can send out an online cry for advice from their more experienced peers when they find themselves in a situation that they don’t know how to deal with.

Cape Town Embrace is working with mothers and babies in the first 1000 days, monitoring, educating and supporting them. They have found that the pregnancy and birth experience of these mothers hugely affects their ability to bond with and parent their children. While there has been much emphasis on skin-to-skin contact and on the value of breastfeeding and mother-to-mother support, Cape Town Embrace is now looking at ways to better support mothers in pregnancy and during the birth. Plans are afoot to provide antenatal education during the pregnancy and doulas during the labor and birth.

South Africans generally have access to adequate medical facilities and medical interventions (although sometimes it can take the ambulance thirteen hours or more to arrive in the rural areas). Operation Smile, who has in the past been providing surgery for children with cleft palates, is responding to the call for improvement of maternity care Africa-wide by instituting, supporting and funding maternity programs. These include the Helping Babies Breathe program, the Saving Mothers program, and they have recently begun focusing some of their fly-in surgery teams elsewhere in Africa to operate on young girls who have developed obstetric fistulas as a result of poor nutrition, rape or lack of access to medical facilities.

The idea that changing consciousness around birth can be fun and exciting is gaining momentum. Two years ago it was impossible to speak about the “sacred nature” of birth within the medical establishment, since this kind of language was so foreign as to render it inaccessible. These days, the recognition that something needs to be done to change the existing paradigm is emerging. In retrospect, all of us are waking up to the fact that our primal instinct is to labor and birth in an environment of safety, privacy and quiet support, where we can bond, breastfeed and provide undisturbed skin-to-skin care to our babies. The element of regarding birth with the reverence that we assign to the process of dying is emerging quietly. South African maternity services are awakening to the concept that so many of the issues we are facing with regard to abuse in labor have at their roots a lack of love. It is an idea whose time has come.

References:

Bergman, Nils. December 24, 2014. Personal communication.

Chadwick, RJ, D Cooper and J Harries. 2014. “Narratives of Distress about Birth in South African Public Maternity Settings: A Qualitative Study.” Midwifery 30 (7): 862–68.

Human Rights Watch. 2011. “Stop Making Excuses: Accountability for Maternal Health Care in South Africa.” https://www.hrw.org/report/2011/08/08/stop-making-excuses/accountability-maternal-health-care-south-africa.

Human Rights Watch. 2012. “World Report 2012: South Africa.” https://www.hrw.org/world-report/2012/country-chapters/south-africa.

Jewkes, R, N Abrahams, and Z Mvo. 1998. “Why Do Nurses Abuse Patients? Reflections from South African Obstetric Services.” Soc Sci Med 47 (11): 1781–95.

Seepie, Zinzile. December 23, 2014. Personal communication. 

Robyn Sheldon is a South African midwife offering a variety of services ranging from Soul Integration sessions, which seek to enable pregnant parents to connect on a soul level to their unborn babies, to training medical students and midwives in compassionate care. Her birth preparation classes assist parents in creating sacred and meaningful births for themselves and their babies.

Dehumanisation of Birth in South African Maternity Systems, and Possible Solutions

Recently I attended a birth at a government facility in Cape Town. I am a midwife living in South Africa and working for The Compassionate Birth Project which focuses on reducing obstetric violence by empowering frustrated, overworked, underpaid midwives to value themselves and their peers. The rationale behind the project is that when maternity staff feel valued they are less likely to take their disempowered frustration out on laboring women. 

My client had been transferred to high care for an obstructed labour and was awaiting a Caesarean section. Seven long waiting hours as the theatres were exceptionally busy that day. During that time, whilst managing intense contractions as best she could, a doctor, perhaps she was a paediatric registrar but we were never introduced to her, brought a tiny, twenty two week gestation baby into our rather small labour room. It had been born in the room next door where presumably there was no resuscitation equipment, and it was not considered viable. The doctor hooked it up to a heart monitor. It had a heart rate of thirty beats per minute instead of the usual one hundred and forty. And then the doctor, having still not acknowledged our presence, wandered off in a desultory fashion and left it there to die.

The frightening thing about the fifty minutes that this gorgeous little being spent with us before finally being returned to her mother where she should of course have been all that time (I think she was a little girl), was that staff members came in and out, peered at her, looked at us, and left again, with no word to us, no recognition that my client or the baby were people, and no concept that there was anything happening that was unacceptable. The premature baby eventually died about ten minutes after being returned to her mother, and then was brought back into our room, dead, to have her head measured and for a physical exam.

When the midwives and Drs checked my client most of them did so without introducing themselves, without explaining procedures like breaking her membranes, before doing them, or without explaining their findings after checking cervical dilation. In fact they managed to do most of their work without even looking at her. It felt rather as if she was a bit of a nuisance in the way of them doing their work.

This can’t really be called obstetric violence, of which there is much recorded evidence in South African maternity centres. It is simply a lack of genuine care. According to a report compiled by The National Committee for Confidential Enquiry into Maternal Deaths in South Africa, ‘60.4% of all maternal deaths were thought to be possibly or probably avoidable. This indicates a poor quality of care, but also by improving the quality of care there is the possibility of reducing maternal deaths.’

It also indicates a level of compassion fatigue that is almost incomprehensible. One of three markers for burnout used by the Maslach Burnout Inventory is cynicism or ‘de-personalisation towards recipients of care’. When we are worn down we become cynical. I have heard obstetric consultants refer to medical students as being in their ‘pre-cynical’ and then their ‘cynical’ years of training, instead of their ‘pre-clinical’ and ‘clinical’ years. As part of the Compassionate Birth Project programme, we meet with fourth and fifth-year medical students in tutorials to address issues such as burnout and to give them space to speak about their initial discomfort at the level of depersonalization of both themselves and their patients in the wards. Many of them have never been asked how they are feeling, or how they are coping with the intense pressures of their schedule.

If burnout is the problem, what are the particular stressors in maternity that create extreme burnout and resultant depersonalization of patients?

Women often experience intense pain in labour. The pain is exacerbated when they are frightened, and our maternity system does little or nothing to decrease fear in patients. There is no recognition that fear is unhelpful, it is simply seen as an irritation most of the time. However, the woman in labour will finally have her baby, then she will go home and hopefully bond with it happily. The staff in the maternity wards simply move onto the next patient in pain, and the next, and the next. Occasionally up to thirteen babies born in a twelve-hour shift, with only one midwife on duty.

They also leave work to go home to busy after hour care of their own children who are growing up in a violent society where they are not always safe.

Then they carry enormous responsibility at work. If a patient or a baby dies, fingers are pointed, and staff in maternity wards need to cover their backs, follow protocols and make sure that those fingers aren’t pointing at them. No fingers get pointed for not loving a woman enough in labour, or for not acknowledging her feelings. Or for shouting at her, or sometimes slapping her to make her behave, to please, please, please give them a break, and just behave!

It’s not really a whole lot of fun!

And finally we need to look at the dynamic of bully behavior. Firstly, we may only feel okay about mistreating people if we can objectify and depersonalize them, otherwise it is too painful for us. Secondly, when we are frustrated, and have no acceptable outlet for it, we take may that frustration out on those who are more vulnerable than us. Disempowered people who feel unrecognized and under-appreciated may turn into bullies.

Historically South Africa disempowered the majority of its population. The legacy of apartheid still runs strongly in the domestic and sexual abuse meted out to women and children, where we have the highest rate of rape in the world.

Midwives are not exempt from this legacy, and many of them report domestic violence at home. If a midwife has been traumatized sexually herself, it could create discomfort for her to witness someone else experiencing pain and helplessness associated with her genital and uterine area, and has the potential to trigger intolerable feelings.

Compare this scenario to a good birth. As a sixteen-year-old, rather frightened pregnant girl Lindii Mandyo wasn’t treated well in the hospital when she went for antenatal check-ups. Teenagers often report that they are shamed by midwives for falling pregnant and are punished in the hope that they will learn a lesson. She said “Nurses, when they were checking the baby, they made no communication with me”.

So she decided to give birth with an independent midwife. Lindii says “I called my midwife. Yo, it was sore. I started to cry.” And sometime later “I saw blood. I was scared – no-one mentioned blood. (But) My midwife was so chilled….. A lot of hours later at 5.00 in the morning I gave birth to baby Mikhaya. It was like, everything was so perfect. It was nice. Ya.”

How then do we address this systemic problem of dehumanization in our maternity wards?

Just as love comes from being loved, so a caring attitude grows from being cared for.

The Compassionate Birth Project is a systems based programme which offers staff working in public maternity units, from midwives and doctors to clerks and security, a process to discover the human compassion within themselves, empowering them to provide more holistic, patient-centred care – where every mother and every infant matter.

Mothers and infants need to feel respected, safe and loved during labour and birth. Studies have found if we offer this kind of care women have:

  • Decreased length of labour
  • Decreased pitocin use
  • Decreased use of epidurals
  • Decrease use of forceps and vacuum extraction
  • Less intrapartum analgesia
  • Decreased cesarean section rates
  • More satisfaction with their birth experiences
  • Improved self-esteem 

And their babies have:

  • Better 5-minute Apgar scores
  • Better bonding with their mothers, with resultant improvement in breastfeeding rates and decreased stress biomarkers.

Maternity caregivers need to show compassion during labour and birth, because doing so offers the following benefits:

  • Improved working atmosphere for staff members with decreased stress levels
  • Increased sense of well-being and self-respect amongst midwives
  • Improved staff-patient interactions and decreased abuse of labouring women
  • Improved birth outcomes
  • Improvement in the Sustainable Development Goals of:

– Reducing under-five mortality

– Reducing maternal mortality

  • Cost benefits in terms of reduced numbers of obstetrics interventions and/or necessity of referral to hospitals
  • Decrease in expensive litigation. At a medico-legal summit in Pretoria in March 2015, South African Minister of Health, Dr Aaron Motsolaedi, stated that “Unprecedented levels of litigation for alleged malpractice by doctors have crippled South Africa’s health system” Obstetrics is under the most pressure for escalating litigation. Patients who are satisfied with their births are less likely to sue the medical system.

The Compassionate Birth Project has been designed to help improve compassionate care by offering midwives and maternity staff a place to feel loved, supported and cared for themselves. The Compassionate Care Course runs for 30 weeks – One and a half hours per week on site at some of the Midwife Obstetric Units in the Western Cape.

The course has 10 modules. Each of the 30 sessions begins with a safe listening space for a check-in and a review of the previous week’s session. This safe listening space is a core component of all the modules. Every class begins with an exercise in building present moment awareness, deep breathing, a short guided relaxation and a check-in. ‘Time to Think’, mindful awareness and Non-Violent Communication are taught as ways for the maternity staff to be present to their own feelings. Gratitude journals, massage techniques, singing and dancing are all introduced as methods to de-stress and to deal with burnout. Tutorials on up-skilling midwives in more compassionate care with recommendations on delaying umbilical cord clamping, and on skin to skin contact between mother and baby are given. Included in this part of the programme are discussions on sexual abuse and how it might affect women in labour.

Underlying the principle of improved care for women and their babies at birth lies the fundamental principal of Ubuntu, as expressed by our beloved Archbishop Emeritus Desmond Tutu when he says, “My humanity is bound up in yours, for we can only be human together.” It is a concept that is integral to community life in South Africa, and one that has the potential to change the face of birth in our maternity wards in South Africa.

References:

Joan Klagsbrun, Ph.D. Listening and Focusing: Holistic Health Care Tools for Nurses.

Jessica Wooliscroft. Freedom and oppression in therapeutic space: How do trauma therapists protect the therapeutic milieu? A heuristic study.’ University of Chester. 2010

Mindfulness-Based Stress Reduction for Health Care Professionals: Results From a Randomized Trial. Shauna L. Shapiro Santa Clara University. John A. Astin California Pacific Medical Center. Scott R. Bishop

Jane Branscomb (2011), Summation Evaluation of a Workshop in Collaborative Communication, M.A. Thesis, Rollins School of Public Health of Emory University.

Gates, Bob; Gear, Jane; Wray, Jane (2000). Behavioural Distress: Concepts & Strategies. Bailliere Tindall.

Inbal Kashtan, Miki Kashtan, Key Assumptions and Intentions of NVC, BayNVC.org

Harry Mills PhD, Natalie Reiss PhD, Mark Dombeck PhD. Kinetic (movement) strategies for Stress Relief.

Lindgren L, Rundgren S, Winsö O, Lehtipalo S, Wiklund U, Karlsson M, Stenlund H, Jacobsson C, Brulin C. Physiological responses to touch massage in healthy volunteers. Autonomic Neuroscience: Basic and Clinical. 2010; 158: 105-110.

Odent M. Birth Reborn. Pantheon (NY). 1984

Thoughts on Expecting Natural Birth Service From Your Doctor……

This article was originally written by Dr Gauri Lowe on December 4th 2012 on FaceBook. She currently resides in India. This article is shared with her permission.


Often I hear and see mothers as consumers comment on their own experiences with doctors or birth professionals comment on their interactions or others experiences with doctors managing birth. So I thought it worthwhile to write about the training of a medical doctor in relation to birth to give a bit of context and perhaps challenge our expectations.

In my 4th year of medical school we did our perinatal block. Now remember we study disease – pathology, aberrant physiology and how to diagnose, manage and treat these harmful states. Now we were studying birth and pregnancy – physiological states in healthy women!

In our clinical time, we spent 2 weeks at a MOU (maternity and obstetric unit). This is a unit run by midwives and designed for low-risk births and pregnancies, any risk factors in pregnancy or labour are immediately transferred to a higher level hospital with doctors.

There my exposure devastated my spirit. The midwives generally used harsh words, called the labouring patients names, evoked guilt for becoming pregnant, for not pushing “right”, when distressed babies were delivered and controlled by shouting. They pushed on the fundus of a contracting uterus, panicked at every step from full dilatation, rushed to cut the cord, contorted the lady to promote pushing (in lithotomy position), often sent out the birth partner. Oh and cut episiotomies without giving local anaesthetic.

But these were the precious 2 weeks of my NORMAL birth training. And it was a relief to find a midwife who was calm, mature and “nice”. We needed them to sign off our logbook and could not risk getting on their “bad side”.

The rest of the time from then our exposure continued in hospitals. Women seen there generally had a risk factor like anaemia, previous caesarian, blood pressure problems, previous intra-uterine death or current twins. Women were monitored by CTG, mostly laboured on the bed and had regular vaginal examinations according to the partogram. Care was mixed with doctor and midwife. Sometimes labours progressed according to the book and other times the intervention according to the protocol was carried out. Ward rounds took place at handover times – and 7-12 doctors and students would briefly crowd around the bed of the labouring lady to discuss her “problems” and progress. And appropriate decisions would be made like “cut, synto, review in 2 hours and then…” Labour wards were full and always busy.

I remember presenting one case on a ward round and I included the social history (her home situation, did she have water, inside toilet and would she breastfeed). I was openly laughed at and ridiculed for taking up the round with this information.

As a doctor – I work currently in a busy district level hospital. A day at the outpatient clinic 2 of us can see in between 40-60 patients a day. When we walk out the office to pee, never mind get a drink or have lunch – we are met with faces that say “Don’t go, I haven’t been seen yet and I have been waiting for SO long now.”

Alternatively we may be seeing inpatients in the wards with different problems that have to be managed…ante, peri or postpartum.

Then we may start our night call….after a full days work – now managing all obstetric and gynae wards including labour and other emergency admissions and theatre. Keeping pace on the possibly 8-10 labouring ladies you have admitted,  before and after you cut an emergency caesarian or an unstable ectopic pregnancy…or evaluating one of the 3-5 miscarriages that present at the emergency unit.

 The home births that cross our path and vocabulary are most often the BBA’s (born before arrival). That is they are not planned home births. They are often unbooked (have not attended any clinic) moms or have other social problems. The exposure of the genuine homebirth in this context is the transferral in or after labour for some “problem” needing an intervention.

In this set up we see medical complications, risks, problems and deaths. We are on alert for diagnosing and managing these problems quickly and effectively. Our continued training is made up of “skills managing obstetric emergencies” like dystocia, haemorrhage, ecclampsia.

So…When expecting your medical doctor to really support, understand and become your attendant at your desired natural birth….remember what has built his experience, exposure and practice. There is definitely the exception who has been pulled and exposed to natural birth. But this is the exception.

Simply – If you want a natural birth chose someone who has had experience in natural birth.

Myself? My next note will be called – “Why I chose a homebirth again.”

(Personally, I look forward to participating in more natural births in a more suitable environment for this expectation.)


For more information on Gauri and her work visit womens-health.co.za

In This Moment I can Only Love you

In this moment I can only love you.

I can only be there for you. Open my heart. And just be.

Open. Empty.

You grip my hand, tightly, your nails digging into my flesh.

You are on your knees, on the floor. Your body bearing down. All concepts and ideas of how to birth are gone and all you can do is just be with your body. Allow your body to just take over.

I am here.

And yet I am not.

I try to disappear because the space you are taking up is huge.

Massive.

The universe groans as it makes space for you to birth this baby.

It does feel as though time suspends itself. It really does.

Nothing else can exist in this moment.

I have to become nothing. Empty. Open hearted. Here. and nowhere else. For you.

You are incredible. Amazing. Did you know that you were capable of this?

I am in awe.

In this moment. I can only love you

What is Oxytocin?

Going into labour is like falling asleep…

Labour is a different state of being, a state of being with a lot of similarities to sleep. For a start, they are both states that cannot be forced. They just happen! Sometimes when we least expect it. We cannot decide or control the moment when we fall asleep. We can also not decide or control the moment when we “fall into labour.” But we can make it difficult for both to happen easily and most effectively.

Labour is like sleep because we need the same conditions to “fall into labour” as we need to “fall asleep.” We need to feel safe and warm and relaxed. We need to be in a place in which we feel comfortable, and we need to be free from pressure, anxiety or fear.   

Oxytocin

When a woman is in labour she releases a hormone called oxytocin. Oxytocin is the hormone that makes the uterus contract during labour.

It is also the hormone of love.

Oxytocin is the hormone we release when we are enjoying a meal, or having a stimulating conversation. It is the hormone we release when we are making love and when we orgasm. It is the hormone that makes us feel in love, and it is the hormone that releases the milk when a mother is breastfeeding.

Isn’t it amazing that it is the love hormone that brings the baby into the world?

In hospitals synthetic oxytocin is often given to women. It has different names like Pitocin or Syntocinon. Synthetic oxytocin is given to make the mother’s uterus contract, which can help to birth the baby. But this synthetic oxytocin is not a love hormone. It is not like the oxytocin that is naturally secreted by the mother’s body. Synthetic oxytocin is just a hormone that contracts the uterus and helps to push the baby out. It is important that we know more about the effects and function of natural oxytocin, because when a labouring woman is under the effect of synthetic oxytocin she may have a decreased ability to produce natural oxytocin. 

How is synthetic oxytocin used?

Synthetic oxytocin is used to induce a labour (this means starting a labour artificially) or to augment a labour (this means to speed up a labour that has stopped or slowed down). Synthetic oxytocin is also used for active management of the third stage of labour when the placenta is delivered (an injection of synthetic oxytocin is given to the mother to help deliver the placenta quickly). It is also used to stop a mother bleeding if she has a postpartum haemorrhage (when the mother’s uterus doesn’t contract after birth and she begins to bleed heavily).

Induction

These days it is very common for a woman to be induced to start her labour. She may be given many reasons for this: she may be over her due date, or her caregivers may be worried that her baby is getting too big, or that her baby is ill, or that she is ill.

Augmentation

When a woman is in labour, it is common for her labour to slow down or even to stop when she arrives in  the hospital. There could be many reasons for this sudden slowing down of the labour: the lights are too bright, she is given a vaginal examination, a stranger enters the room, she is feeling watched or self-conscious, she is feeling rushed, cold or scared. Usually, if the labour doesn’t start up again after a certain amount of time, synthetic oxytocin will be used to get the labour going again. This labour is now very different to the natural labour of the love hormone. This new labour is now governed by a synthetic oxytocin, which has the effect of contracting the uterus without the behavioural effects of the natural love hormone.


The baby, when he or she is ready to be born,

will send a message that tells the mother’s body that it is ready.

The mother’s body can then begin labour by slowly releasing oxytocin, the hormone of love.

The mother and baby work together to bring the baby into the world.

 

The Cape Town Midwifery and Birth Conference

Have you ever been to the Cape Town Midwifery and Birth Conference?

Well, if you haven’t and you are passionate about all things pregnancy and birth related, and live in, or near Cape Town (although people do travel from further afield to attend), you really really should come.

What is the CT Midwifery and Birth Conference and what makes it particularly special?

The conference began in 2013 when a bunch of women, got together and decided that they had had enough of the situation around birth in South Africa (the ridiculously high caesarean rates in the private sector and the abuse of labouring women in the public sector to name but a few). The CT Midwifery and Birth Conference was born and we were pleasantly surprised to find that many other people felt the same way and crowded little Erin Hall so that it was full to bursting!

1901516_592152427539192_1583101971_n 1920456_592152260872542_1353135451_n

1960127_592152147539220_1576723383_n 1966772_592152170872551_1139400311_n 1970411_592152544205847_306266828_n 1970588_592151967539238_766369851_n 1796695_592151944205907_710259529_n 1965044_592152017539233_592404789_n

One midwife who attended said that the conference felt like a home birth.

It is all about sharing and collaboration. It is about hearing the stories of all of those invested and affected in the services provided.

Mothers. Fathers. Families. Midwives. Doctors. Doulas. Birth Activists. Lactation Consultants. All those affected and invested – especially those on the receiving end.

The next conference (our third) will take place on the 30 – 31st of October 2015 at the Observatory Community Centre.

For more info and for the full programme and list of speakers, have a look here:

Cape Town Midwifery and Birth Conference official website

And here is the direct link if you want to book your ticket:

Get your tickets here

About the Project

The Compassionate Birth Project (CBP) will improve the quality of the birth experience for South African women by developing a culture of compassion in the public health care sector. Our vision for the CBP includes four broad elements.

1.     Compassion training for maternity healthcare workers (MHCW).

Compassion training will include modelling compassionate birth practice for MHCW, mothers, and babies, such as:

·       Training of facilitators, train-the trainers for midwives to model compassionate birth

·       Establish a compassionate birth facility at a public hospital or MOU to model compassionate birth to health care providers after their compassion tutorials/refresher courses

·       Integrate into midwifery curriculum

·       In-service compassion tuts and refresher courses

2.     Antenatal birth preparation and perinatal education for the empowerment of women.

Regular sessions would include:

·       Screening of videos on compassionate birthing techniques and their impacts on mothers and babies

·       Free, illustrated, multilingual, culturally relevant  information booklets

·       Training for women to manage the physical aspects of labour e.g. breathing, use of different positions

·       Teaching partners/husbands/relatives how to participate meaningfully during the process of birth

·       Addressing fear of birth[i],[ii] that exists within South African maternity systems, which is shown to increase length of labour[iii], [iv], [v] and foetal distress[vi] and decrease maternal self-esteem[vii] with potentially negative bonding implications[viii]

·       Empowering labouring women to know their rights, and to expect compassionate treatment in labour

3.     The option of a doula for every labouring woman
Community Health Workers would be trained as doulas, as evidence suggests that doulas improve birth outcomes.[ix] A meta-analysis from The Cochrane Collaboration 2010[x] reported women with continuous labour support from a doula were:

o   28% less likely to have a Caesarean section

o   31% less likely to use synthetic oxytocin to speed up labour

o   9% less likely to use any pain medication

o   34%less likely to rate their childbirth experience negatively

4.     Debriefing and support for maternity healthcare works to prevent workplace burn-out.
A menu of options to support every midwife at participating sites would include:

·    Monthly debriefing groups run by skilled facilitator or access to single one-on-one debriefing sessions provided by appropriately trained personnel and  biyearly workshops to provide refresher training

·     Individual adhoc sessions for debriefing and conflict resolution where needed

·     Feedback, self-care ratings and acknowledgment of improved care within ongoing education and development of all health care professionals aligned with structures of the Western Cape Department of Health, in the Western Cape

Why focus on compassionate birth in South Africa?

We aim to decrease the abuse of labouring women and improve health outcomes for labouring women and babies. Labour is a vulnerable time in every woman’s life, however, abuse of this vulnerability is marked in South Africa where:

·       Conditions of employment create stressed, overworked and underpaid maternity health care workers in the public sector

·       South Africa’s history of Apartheid has led to unhealthy power dynamics, where nurses are often still significantly inferior to doctors and other figures of authority in the health care context

·       Violence in communities and domestic violence is an ever present stressor in the lives of midwives and nurses

·       South African women do not generally have access to teachings on the physical and emotional aspects of labour and birth

·       Women delivering in State funded facilities frequently do not know their patient rights

·       Abuse of labouring women at the hands of midwives and doctors has been documented throughout South Africa[xi],[xii]

·       South Africa is one of only 6 countries in the world whose maternal mortality rate has risen since 1990 – instead of dropping to a third of its 1990 levels in order to meet the MDGs by 2015[xiii]

[i] Great Expectations A Prospective Study of Women’s Expectations and Experiences of Childbirth.  JM KitzingerJV Coupland (1998)

[ii] Reduced pain tolerance during and after pregnancy in women suffering from fear of labor Terhi Saisto*, Risto Kaaja, Olavi Ylikorkala, Erja HalmesmaÈki Department of Obstetrics and Gynecology, Helsinki University Central Hospital, P.O. Box 140, Haartmaninkatu 2, FIN-00029 HUS, Finland Received 21 August 2000; received in revised form 23 January 2001; accepted 13 February 2001

[iii] Buckley Sarah J. MD. Gentle Birth, Gentle Mothering: A Doctor’s Guide to Natural Childbirth and Gentle Early Parenting Choices , Celestial Arts, 2009. Pain in Labour. Your Hormones are Your Helpers.

[iv]Laursen M, Johansen C, Hedegaard M. Fear of childbirth and risk for birth complications in nulliparous women in the Danish National Birth Cohort. BJOG. 2009 Sep;116(10):1350-5. Epub 2009 Jun 17.

[v] Bak. C. The role of fear in the U.S. birthing process. Midwifery Today Int Midwife. 2003 Fall;(67):24-7.

[vi] Wolf, Naomi. Misconceptions. New York: Doubleday (2001)

[vii] Lowe NK. Self-efficacy for labor and childbirth fears in nulliparous pregnant women. Journal of Psychosomatic Obstetrics and Gynaecology. 2000 Dec;21(4):219-24.

[viii] Lederman R, Weis KL. Psychosocial Adaptation to Pregnancy: Seven Dimensions of Maternal Role Development. Prentice Hall, 3rd Edition. 2009

[ix] Hodnett ED, Gates S, Hofmeyr GJ, Sakala C. Continuous support for women during childbirth. Cochrane Database Syst Rev 2007; CD003766. [DOI: 10.1002/14651858.CD003766.pub2].

[x] Hodnett ED, Gates S, Hofmeyr GJ, Sakala C, Weston J. Continuous support for women during childbirth. Cochrane Database of Systematic Reviews 2011, Issue 2. Art. No.: CD003766. DOI: 10.1002/14651858.CD003766.pub3

[xi] Human Rights Watch.  “Stop Making Excuses”.  Accountability for Maternal Health Care in South Africa ISBN: 1-56432-798-1

[xii] Jewkes R, Abrahams N, Mvo Z. Why do Nurses Abuse Patients? Reflections from South African Obstetric Soc. Sci. Med. Vol. 47, No. 11, pp. 1781±1795, 1998

[xiii] UNFPA. The State of the World’s Midwifery 2011. Delivering Health, Saving Lives.