Towards a value-free nurturing of birth

“The birth of a child should be (italics mine) a wonderful, life-changing time for a mother and her whole family. It is a time of new beginnings, of fresh hopes and new dreams, of change and opportunity. It is a time when the experiences we have can shape our lives and those of our babies and families forever”

In these opening words of her letter to the women of England and her families [1], Baroness Cumberlege anticipated the recent shift of emphasis from ‘normal births’ to ‘better births’ in the Royal College of Midwives [2]. Two months ago, the flurry of media describing this shift as a “step-down”, “back down” and even “climb down” [3] by midwives following unfortunate tragedies in NHS Foundation Trusts such as Morecambe [4] dramatized but also exposed the value-laden terms that shape women’s experiences of pregnancy, birth and infant feeding. [5] Every culture on earth has maternity traps for women (ban on twins, priority on boys, legitimacy and many more). In our technology-led culture, maternity professionals balance perceived risks along guidelines for best practice. This occurs  in a context of “choice” for mothers in (in) / a care management made increasingly defensive by the escalation of legal claims and staffing. Is “choice”, or mothers’ perceived denial of it, our cultural maternity trap? (Childbirth NICE pathways).

How to reconcile birth choices with “values” in ideological battles between entrenched camps fighting with “evidence”? In the UK, midwives’ campaign for normal birth  since 2005 been has been aligned with the World Health Organisation’s 1996 Guide to Care in Normal Labor. [6] Reflecting the consensus reached by an international group of experts following a critical review of the effectiveness and safety of 59 common procedures, the guide responds to the proliferation of practices designed to start, augment, accelerate, regulate or monitor the physiological process of labour in industrialized and developing countries alike. (In its laudable attempt to reduce the rise of caesareans above rates that correlate with negative epidemiological health indicators for mothers and babies, WHO opened a Pandora’s box: “natural” childbirth had been discarded decades ago (the N in NCT changed from Natural to National) but returned in a new guise with “physiological birth” flanking “normal birth” and  its trail of failure, inadequacy, anxiety and resentment. Both those mothers undergoing medical interventions that were perhaps unnecessary and those denied the interventions they wished for because of being classified as low risk have had strong grounds to feel unheard, betrayed and affected in long-lasting ways.

At Birthlight, our priority has always been on “respect”, a cornerstone of yoga philosophy, for each woman as she transforms into a mother, whether for the first time or again, in a unique journey with her baby (or babies) and those closely involved around her.  With respect, our remit is to nurture the wondrous physical, emotional and mental changes that women experience, in  ways that are fundamentally similar all over the world, as they become mothers. Around them men are transformed into fathers, parents into grandparents and changes affect siblings, friends and neighbours too in real and virtual communities. Marshall Klaus, the American neonatologist who has done so much to support the care of mothers and newborns in his lifetime, put it in the simplest form: “Mother the Mother” so that she can mother her babies.[7] Nurture, and even more, self-nurture, are rare commodities and rare skills in global maternity care. Our dominant model of care, fragmented into prenatal, intrapartum and postnatal services, does little to support the continuity of new mothers’ (and fathers’) experiences. It is as if the accumulation of research on the “primal continuum”, the inter-related effects of maternal experiences and foetal-infant formative development from early pregnancy through to the end of the first year after birth, remains invisible on a world stage where lead actors insist on wearing blindfolds.  

Faced with a plethora of information, with bloggers’ often indiscriminate opinions and contradictory professional advice - including adverts masquerading as expert advice - women and birthing partners benefit most from access to a safe place where they can just “be” with themselves.  Their experience of growing a baby and relating to this baby as they become parents is paramount. At a time when there is a lot of talk about re-enchanting the world, when is there more wonder and need for a quiet but joyous mindfulness, than during both pregnancy (whichever way it came about) and after birth, when we celebrate newborns and, to use another famous trope coined by Klaus, “their amazing talents”? With body-based skills of “grounding” and “centering” themselves in friendly circles, pregnant women and birth partners can find the space to make choices that are informed not only by external inputs, but more importantly by their personal priorities. We humans are complex beings shaped by our parents’ and even grandparents’ experiences and our own experiences of growing up. There should be no judgement regarding how this impacts on our approach to the mode or place of birth, to infant feeding and style of parenting. Little by little, week by week, month by month, often through turmoil, we can reach a place we can call our own, to nurture ourselves in preparation for nurturing our babies.

I will be forever grateful to the Amazonian women and men who created this space of nurture, previously unknown to me, during my first pregnancy. This was not imparted just in meditative sitting but also through physical activity on land and in water, always with a sense of purpose and lots of laughter that deflated any dreamy expectations as much as feelings of panic about the unknown. Hey, my hosts took responsibility for helping me grow a soul, not just a baby! As the frontiers of knowledge about mother-fetus interactions and their implications recede in time to the early months of pregnancy, women increasingly need support in the first trimester of pregnancy with gentle practices. This is as much a pioneering frontier as pregnancy yoga was in the 1980s.

Regarding birth choices, we cannot ignore the trend towards a “gentle caesarean section” and the possibility that this may become an alternative cultural model in affluent countries. Could this move herald a resurgence of breast-feeding or, on the contrary, displace it further? It is too early to tell. As pointed out by Brazilian colleagues, the high rate of caesarean section is mitigated by a high rate of breastfeeding in Brazil, while the UK has a low rate of breastfeeding irrespective of the mode of birth. Post-birth skin-to-skin contact is on the rise, particularly with dads, but in recent years many new mothers in the UK have aggregated their sense of failure due to an emergency C section with their failure to breastfeed their babies successfully, even though the recent improvements in tongue-tie diagnosis have contribute to mitigate those feelings.

Research shows the links between medical intervention at birth - not only C section but also induction - and greater challenges in the initiation of breastfeeding, but this is clearly counteracted in a positive traditional culture of breastfeeding as with Brazil, and positive institutionalized change as in with Poland.  All over the world, the implications of a C section birth are downplayed in the information available to pregnant women and couples: the general belief that C sections protect the integrity of pelvic floor muscles and preserve vaginal tone; the lack of attention given to adhesions in scar tissue until the following pregnancy; and the not infrequent inflammation of scars at times of stress or transition in women’s life-cycles. These issues all need to be aired publicly. As Michel Odent pointed out long ago, with the risk of being perceived as a doomsayer, the rise of C sections worldwide may have implications for childbirth in human evolution [8], in the same way that the rise of pollutants may have already impacted fertility rates in industrialized countries.

Birthlight trainers and teachers are often asked what the position of Birthlight is on many issues, including birth. Indeed, we read and enjoy exchanging posts on the vast and growing evidence of complex physiological orchestrations and their cascades of benefits. The recent awareness of the microbiome is astonishing. At the same time, we refine our skills of quiet, often silent “empowerment” of pregnant women, birth partners, and new parents and babies in the community, welcoming avenues of integrated maternity care and community support wherever they open. Midwives have felt motivated to join Birthlight and Birthlight teachers have gone to train as midwives to further their realization that embodied skills imparted during pregnancy could impact on women’s experiences in labour wards. “Empowering” has been so overused that it has become discredited but it remains the foundation for confidence in one’s ability to live and “do” something that makes us feel uncontrollably out of control and when possible choose our trajectories.

As noted by the new president of the Royal College of Midwives, consultant midwife and author Kathryn Gutteridge, the psychological and mental wellbeing of women in the transition to motherhood are dominant concerns. The growing awareness that everywhere in the world, the quality of experience in childbirth is not a luxury over and above “safe delivery” of a healthy child to a healthy mother but part and parcel of their lives is a welcome change. Initiatives to improve compassionate styles of maternity care and support the human rights of mothers are contributing to the new campaign for “better births”, with a focus on improved communication between mothers and maternity professionals. [9] That an increasing number of women choose to give birth unattended reflects their perception of maternity in a system of care that generates deep-seated fears of obstetric violence and ignores their motives, particularly after past traumatic deliveries. [10] We are fortunate to live in a country where home births are legal and women’s access of midwives of their choice is being fought for. [11]

Yet again we cannot escape value-laden terms: better indicates an ideal norm that may or may not be achieved.  “Positive birth” has been around for some time, particularly in PBAC (positive birth after Caesarean section) in replacement of VBAC (Vaginal Birth), making room for the eventuality of a repeat C section, albeit experienced in a positive way. While it gets rid of normative associations, “positive” also points to the mind frame that interprets experience by maximizing beneficial outlooks for self and others. This is a welcome term, and the increase of positivity through exchanges in peer groups of experiencers can be greatly enhanced by social media as well as by local face-to-face initiatives. [12]

From the start, Birthlight has aimed to “create community” through value-free circles in which women could freely express their fears surrounding giving birth, and grow friendships based on acceptance of contrasting birth scenarios and infant feeding choices. Last Summer I had the delightful surprise visit of a birthing cohort of women that bonded in Cambridge 25 years ago in my local WellWoman Yoga class, some of them with their daughters. I was reminded that the local groups that are formed around Birthlight practitioners are ferments of positive change not only in a drive to achieve “better births” but in their respectful acceptance that every pregnancy, every birth and every baby are unique, unpredictable and wonderful in being so. This does not mean that we do not have personal values - and sometimes, strong opinions. We all do! But through imparting body-based skills that are based on self-acceptance, centering and grounding, as well as on a creative enjoyment of movement, we reach “hearts and minds”. Sometimes the breath or voice becomes a path of communication between mum and baby, or mum, dad and baby, eliciting a foundation for positive bonding that goes beyond anything read or seen because it has been experienced deep within.

At present, our Birthlight priority is to positivize the experience of the early postnatal period for new mothers and their families as well as promoting better birth experiences. Just as growing social inequality has resulted in a more widespread use of home nannies in rich countries, and traditional kin networks are dismantled by rural-urban migrations in many parts of the world, new mothers increasingly take the brunt of the deficiency of postnatal care and support in global maternity services.  However ecstatic a birth is, it requires a range of intense and intensive physical, emotional and mental re-adjustments for new mothers as they care for their newborns, even if fathers are increasingly willing to share in this care. Beyond birth recovery, holistic postnatal support can help mothers resolve previous traumas such as pregnancy loss or abortion and harmonize difficult relationships that might otherwise remain unattended. The birth of a mother, as Bernard Siegel points out, does not necessarily happen during childbirth but in the weeks and months that follow. When mothers have not been sufficiently “mothered” during pregnancy, there is another window of opportunity to do so right at the start of their mothering career, in the most vulnerable phase of the postpartum.



Birthlight aims to contribute to birth recovery with home visits by perinatal teachers and with volunteer mother-to-mother help in the community to cover the gap between birth and the time when women are ready to leave home to join small circles of new mothers and their babies for nurturing baby massage, relaxed holds and postnatal gentle practices. The Postnatal Centres set up all over China in continuity with the traditional practice of “doing the month” offer an example of communal solutions, but other models may be better suited to new mothers outside Asia.

If I ever had any doubts about the value of postnatal nurturing circles, attending the Birthlight group my daughter and new granddaughter were part of strengthened my motivation to make postnatal support in the community a Birthlight priority.  The flow of oxytocin from mothers to babies, babies to mothers and mothers to mothers spread all over the room. Faces transformed, babies were visibly content and after resting, mothers clearly responded to them with renewed energy, triggering smiles in return. The simplicity of it all amazed me most. This could not have happened at a mums & babies’ coffee morning.  The  togetherness of guided practice creates an experience that in turn promotes the social bonds between mothers.

In an ideal world, the continuity of care advocated so clearly by our patron Dame Lesley Page, the former president of the RCM, [13] would be complemented with continuity of support in the community and the two would consolidate each other. In an uncertain world, the quality that children will need most, even beyond emotional intelligence, is resilience. The best place and time for acquiring this quality, and beyond it, “joie de vivre” is in the womb, through mothers’ welcoming.

Returning to the words of Baroness Cumberlege and her declared wish for a new “normal” of birth it seems apt to turn the “should be” around, with an affirmation of what is. The birth of a child IS wonderful and life-changing. When we are able to silence the chatter of opinions and doubts, and in dark times, receive just enough support to lift the veil of depression for a moment, this acknowledgement and flash of awareness can propel us into a life-long enjoyment of parenting in which perhaps the most challenging birth experiences are also the most cherished.

Françoise Freedman
Birthlight Founder & Director

 


 

[1] 2016 National Maternity Review, https://www.england.nhs.uk/wp-content/uploads/2016/02/national-maternity-review-report.pdf)
[2] http://betterbirths.rcm.org.uk/
[3] The Consensus Statement from the Maternity Care Working Party (2007) is used for data collection and measurement of ‘normal births’ (vaginal births without the use of technology or medical interventions, excluding the onset of labour using induction methods, pain management such as epidural or spinal anaesthetic, and the use of forceps or ventouse).
[4] The RCM campaign for normal birth was criticised in an inquiry into the deaths of 16 babies and three mothers at Furness general hospital in Cumbria between 2004 and 2013.The investigation found that a “lethal mix” of failings led to the unnecessary deaths of 11 babies and one mother treated at the hospital’s maternity unit, part of the Morecambe Bay NHS foundation trust.
[5] Approximately 40% of mothers in the UK give birth without medical interventions, compared to three decades ago when 60% did so. Women’s age at the birth of their first child has increased to 28.5 years in 2015 from 21.4 in 1970 and 24.9 in 2000, leading to an increase in complications.
[6] http://apps.who.int/iris/bitstream/10665/63167/1/WHO_FRH_MSM_96.24.pdf).
[7] Marshall Klaus died last August. Despite controversies about his theory of a neonatal sensitive period for bonding, his legacy of change in labour ward protocols (skin to skin contact and the presence of doulas as birth companions) and his presentation of research on newborns to the wide public need celebrating.
Your Amazing Newborn,  (1985) new edition by Da Capo Press, 2000. Film: 1987.
Marshall Klaus, John Kennell and Phyllis Klaus 1993 Mothering the Mother: How a Doula Can Help You Have a Shorter, Easier and Healthier Birth. Perseus Books. Photographs by Suzanne Arms.
[8] A recent article published in the Proceedings of the National Academy of Sciences examines the growth of the global rate of feto-pelvic disproportion from 3 percent of births in the 1960s to 3.3 percent of births today, a rate of increase of 10 to 20 percent, with possible correlations (rather than established causal links) with the global rise in birth caesarean section.
[9] Byrom, Sheena and Soo Downe eds. 2015. The Roar Behind the Silence: Why kindness, compassion and respect matter in maternity care. Pinter&Martin.
Lokugamage, Amali. 2012. The Heart in the Womb. @integratedmedic. Watch on YouTube (Dr Amali Lokugamage discusses ways in which every woman can aim to give birth in the most natural, supportive way possible, and looks at the wider implications for society at large.) www.theheartinthewomb.com
[10] Cooper, T.; Clarke, P. (2008). "Birthing alone: a concern for midwives?". Midwives. 11 (4): 34–35. PMID 24902266. Retrieved 1 June 2017. https://www.theguardian.com/lifeandstyle/2013/sep/14/freebirthing-birth-without-medical-support-safe Saturday 14 September 2013
[11] #savethemidwife campaign, October 2017. A coalition of the Association of Radical Midwives and various birth activist groups to  protect Women’s Rights with Better Midwifery Regulation to counteract the Nursing and Midwifery Council’s restrictions placed on independent midwifery practice https://www.nmc.org.uk/news/news-and-updates/indemnity-provision-for-imuk-midwives-is-inappropriate-says-nmc/.

 

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