August 16, 2006
Volume 8, Issue 17
Midwifery Today E-News
“Working Abroad”
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Can you work in a hospital without compromising your values?

A hospital is nothing more than a building with people: people are the problem. How do we bring out the compassionate part of our colleagues to make a sacred space for women to work their miracle? Learn what you can do at the full-day "Humane Hospital Birth" class with Barbara Harper, Marsden Wagner, Lisa Goldstein and Debra Pascali-Bonaro. This is a must-attend class for any midwife or birth professional who attends hospital births and is part of our conference in Bad Wildbad, Germany, October 2006.

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Plan to attend our Eugene conference in March 2007. You'll be able to choose from classes such as:

  • Beginning Midwifery
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  • Herb Walk

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In This Week’s Issue:


Quote of the Week

"No woman who has experienced or witnessed or read about our careful, gentle management of third stage would agree with the standard "active" management."

John Stevenson


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The Art of Midwifery

The emotional state of fear on the part of the birthing woman can have a negative impact on the progress of her labor and her overall experience of birth. Slowing down or arrest of labor [is a] physiological phenomenon observable in animals, whose bodies instinctively cease to labor when a threat is perceived. The way to deal with fear is to help the birthing mother discharge the adrenaline flooding her system by having her engage in strenuous exercise. If she is encouraged to simulate fighting off a predator by beating pillows for about twenty minutes, labour will resume in the majority of instances, without unnecessary pain or distress.

Rayner Garner


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Passionate Midwifery Education

Apprenticeship, Part III

This is the last of three installments from the article "Apprenticeship: Do You Really Want One?" by Renata Hillman in the Midwifery Education issue of Midwifery Today, Issue 78, Summer 2006. You can read many more articles on paths to midwifery education by buying this issue.

5. Friendship/Loyalty. I suppose some apprenticeships exist without this; they may see their work as just business. Within my practice, however, friendship and loyalty are essential. How can you spend three long days at a birth that ends up in a transport with a person who isn't loyal? How can you openly grieve the loss of an infant with a non-friend? How can you openly communicate your fears about the complications, legal issues, money problems or the effects on your family with anyone other than a friend whom you know to be loyal to you?

As a midwife, I know the feeling of having that loyalty broken and the friendship voided. That experience was the most unsettling I ever experienced in my practice. Up to that point, I had naively opened up my practice and confided freely, believing all seekers were loyal to me in return. As is the case with integrity, not everyone has this quality. Both midwife and apprentice need to carefully evaluate their views on the relationship within the apprenticeship. Do you seek to keep it strictly business? Do you choose to open up all your personal and practice information to this person that you are just getting to know? How does each of you feel about the apprenticeship developing into a friendship? How much loyalty does each of you expect from the other?

Those who are seeking an apprenticeship need to remember that apprenticeships of the past were usually financed by parents. The apprentice worked very hard, usually for several years, to learn the vocation of the mentor. The mentor was not obligated to take on an apprentice and usually the position was in demand.

Apprentices need to make themselves worthy of the position, developing skills, studying, gathering equipment and being ready to learn to serve the midwife's clients and the midwife. In addition, they should expect to be willing to communicate their desires, needs, limitations, skills and, especially, birth philosophies. If apprenticeships increase the midwife's workload they will likely be few and far between. Midwives usually are already heavily burdened by the needs of the expectant mothers they serve, as well as their own families; taking on an apprentice is a gift and should be recognized as such by the apprentice.

For midwives who are considering apprenticing as a way to pass on what they were given, I recommend a few things that may help prevent some of the mistakes I made:

  • Clearly share your expectations in writing to prevent later misunderstandings.
  • Clarify time requirements and limitations.
  • State up front any fees that you will charge the apprentice, or whether she is to be paid.
  • Inform her of equipment that she will be required to purchase.
  • Share other study or academic requirements.

I share this information with a heart that desires that midwifery not only grow but thrive once again in our country, for us and for the sake of our granddaughters. I wish for all midwives-to-be to find a midwife willing to share what she has been given. I wish for all midwives to find apprentices who will assist their practice and clients.

Renata Hillman

Renata Hillman is a Traditional Midwife, serving mothers along the gulf coast, as midwife and educator. She is mother to three and midwife to her first granddaughter. She is the Chairman of the Board for Midwives Alliance of Mississippi (MAM). She dreams of the day when midwifery is once again a respected calling in American society and mothers have many from which to choose.

To read all installments of this column on midwifery education, go to our Better Birth and Babies Blog.


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Working Abroad

Following are seven recommendations for caregivers who wish to work outside their own culture:

  1. Learn the language and be at least conversant in it. Don't assume everybody in the world speaks English. The doctors in the office in the capital city in the Ministry of Health might speak English, but certainly the midwives in the villages or women and families with whom you may be working will not.
  2. Identify what you want to do, specifically. "Be of help" is a nice intention, but get it more focused: Do you want to train others? Evaluate programs? Attend in childbirth? If you want to train, you need to decide for what you will be training and to whom this training will be directed. Where will you work? In hospital settings? In homes? What do you know that you think someone else doesn't?
  3. Identify the country where you want to work. Why did you choose it? Did your great-grandparents emigrate from there? Are you fascinated by the history or art of this place? Do you know anything about it? Study the cultural norms, belief systems, religion and how it affects childbearing women. Do your homework. Learn the political history and how that affects healthcare service provision. Are there clinics? Roads? Accessibility? Emergency medical supplies?
  4. Study documents from the World Health Organization or from nongovernmental agencies that have already been making health care interventions in that country. Search the Web and visit the public library. Librarians love to investigate! For example, who are the major players in maternal healthcare in Guatemala? As a matter of fact, they are mostly from Germany (the programs are funded by GTZ, the equivalent to USAID). Also, MotherCare has been there for more than 10 years and has published many documents and "working papers." MotherCare has also been active in Nigeria, Indonesia, Egypt, Russia and Bolivia for many years. Get to know what's been done and by whom. By investigating you will also learn the language of these international organizations.
  5. Target your list of future employers. What do you have to offer them that they don't already have? An easier way to target your employer from home is to access publications that specialize in this sort of thing, such as the National Science Foundation, Office of Scientific and Engineering Personnel, National Research Council and National Academy of Sciences, International Career Employment Opportunities, and International Population Non-Governmental Organizations.
  6. Determine your availability. Do you have small children you want to take along on this adventure? Think about the very real possibility of infectious and contagious diseases, some of them quite deadly. Think about isolation (don't consider dragging your laptop to a place where they don't even have electricity, let alone telephones), inconvenience (no toilets, toilet paper, or tampons), no transportation if you need to get out, no convenience foods.
  7. Think of the adventure of a lifetime and how you, one person, can really make a difference.

Ann Davenport
excerpted from "Opportunities for Working Abroad"
Midwifery Today Issue 53


UNICEF, WHO, and those engaged in implementing the Safe Motherhood Initiative have for two decades centered their efforts to reduce maternal and perinatal mortality in the Third World around "TBA [traditional birth attendant] training"—short, usually two-week-long courses taught by medical personnel, usually doctors, nurses, or professional midwives to community midwives. The purpose of these courses has generally been to educate TBAs about the risks that require transport and to improve their prenatal and maternity care. Almost always, these courses are designed by biomedical personnel trained in biomedical institutions to think about and manage birth in biomedical ways. Very seldom do the "trainers" enter a community and spend time there learning about the indigenous birthways before they try to intervene. Rather, they attempt to educate traditional midwives in biomedical ways of thinking that are often totally inappropriate to local circumstances and realities.

Example: A British midwife went to Uganda some years ago to work in a public health clinic serving the Karimoja. Maternal mortality rates were high among this group, and she wanted to improve maternity care. She had been trained to think that the western system was the best; nevertheless, it occurred to her that it might be a good idea to learn about the indigenous system before trying to change it. … It turned out that the indigenous system didn't really need changing; the problem lay, as it so often does, in the interface between the biomedical and the indigenous systems. Karimoja midwives who transported had often been rudely and dismissively treated, so they tended to hold on at home longer than was wise in order to avoid subjecting themselves and their clients to such disrespect. The midwife's solution was to bring the clinic staff, two at a time, to the weekly meetings she had been holding with the midwives. As the staff developed more respect for the community midwives, they invited them to the clinic for tours and get-acquainted sessions. Then when the midwives transported, their advice was respectfully solicited and listened to, and they were invited to remain with their clients and give labor support. The British midwife called this model of mutual accommodation the "partnership paradigm."

Robbie Davis-Floyd
excerpted from "Mutual Accommodation or Biomedical Hegemony? Anthropological Perspectives on Global Issues in Midwifery"
Midwifery Today Issue 53


Midwifery Today Issue 53 can be ordered.


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Research to Remember

A University of Oulu, Finland, longitudinal study of 234 pairs of twins from fetal life to age 21 examined parental preference and correlated outcome. Personal interviews of twins and evaluations completed by parents suggest that mothers' favorites had learned to speak earlier and were more often the "psychic leader" of dyads, but also had increased incidence of sleep and other psychosomatic difficulties. However, they did not score in the higher levels of possible or probable psychiatric disorder. The study outcomes also suggest fathers' favorites were more often the physical leaders of the pairs, were less prone to accidents, and tended toward more autonomy from their twin sibling. Researchers advised that parents share equal time with each twin offspring.

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Web Site Update

The ENTIRE PROGRAM for our domestic conference in Eugene, Oregon, in March, 2007, is now online. Don't miss out on your first choice of classes…register early! Start on the Eugene gateway page.


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Forum Talk

I was nine days overdue with my daughter, my first child. I was induced with gel and proceeded to have regular and strong contractions. I had been in labor for an entire day when my doctor came in to examine me and break my waters to speed things up. Well, she's feeling around in there and is telling me that she thinks the baby might be breech! She thinks she feels the bulging of what might be the scrotum (we didn't know the sex), and everyone is now feeling my belly to see if they can tell. The L&D nurse states assuredly that it's head down, but my doctor wants to be sure and gets the Ob/Gyn on call. He palpates me and can't tell so they bring in an ultrasound. Finally it's clear, the babe is breech and I'm in for an emergency c-section instead of my planned natural birth.

How could nobody have known this? I weighed 150 lbs at full term, my daughter was a good 8 lb 1 oz—how could they have not felt where she was? She was a frank breech, so I understand her bum is round too, but really. … I remember thinking that the last couple of weeks my belly did look different to me, rather bulgy and hard up top and I had a lot of movement and never dropped. Anybody have experience with this sort of thing?

Jenny


Go to our forums to share your thoughts and experience.


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Question of the Week

Q: Is it safe to use Epsom salts in the bathwater during labour and to remain in the same bathwater during the actual delivery (can it harm the baby or placenta)? I know Epsom salts are fantastic for relieving muscular pain, but would they reduce the action of the uterine muscles and therefore prolong labour? I experienced a 76-hour labour with my daughter, so I am looking for ways to relax and to hopefully prevent the same thing happening again with my next birth. I am using a birth centre with midwives only attending me, plus I intend to use herbal teas and tinctures, essential oils and visualisation.

— Caron Kambi


SEND YOUR RESPONSE to mtensubmit@midwiferytoday.com with "Question of the Week" in the subject line. Please indicate the topic of discussion *and the E-News issue number* in the message.


Question of the Week Responses

Q: My stepdaughter's doctor told her if she didn't drink more water that she could go into premature labor. She is due in mid-August. Is this true, and if so, why?

— Tammie

A: I had dehydration, causing premature contractions, with my second child. Thankfully my contractions were mild, and dehydration was mitigated by IV fluids (6 liters of L.R. + 1 of dextrose, and I hardly eliminated any). Yes, this is true. The cervix and uterus are particularly sensitive to proper hydration.

— Vesper Stamper, CCE

A: Dehydration can definitely increase the number of contractions a woman feels in late pregnancy. Often if a client of ours is having painful, short contractions that are uncomfortable or keeping her awake at night, we ask about her fluid intake, especially if she is due in the summertime when it is so much more difficult to keep hydrated. The uterus is a smooth muscle, which means it wants to contract and release automatically (like your heart, or intestines) and is actually contracting about every 20 minutes, whether you feel it or not. And when you're dehydrated you feel those contractions much more easily. We have never had trouble with dehydration actually causing preterm labor, but it may aggravate it if there are other risk factors.

— Katie

Q: My husband and I are both 35 and have two children, 9 and 11 years old. We are trying to conceive for the sixth time, as we've experienced three early pregnancy losses with no known cause. (I have two minor heart conditions which are unrelated to the losses.)

In my first pregnancy, I went into preterm labor at 32 weeks and after strict bed rest and the use of Brethine, I carried to 36 weeks and gave birth (hospital with an obstetrician) to a healthy 7 lb 10 oz boy. In my second pregnancy, I went into preterm labor at 25 weeks. It was a much more difficult pregnancy and I was on strict bed rest for 11 weeks and took Brethine again. I managed to carry to 36 weeks and gave birth (hospital again, although with a midwife) to a healthy 5 lb 12 oz boy.

In each pregnancy, I was diagnosed with extreme hyperemesis and even had home-nursing care and IV hydration at home and during occasional hospital stays. I had sickness, vomiting and extreme dehydration for almost seven months of my pregnancies.

I didn't make it past 11 weeks in my last three pregnancies. We are now seeking fertility treatments with a reproductive endocrinologist because we haven't conceived in over eighteen months. After we do become pregnant, I would like to pursue homebirth, but my husband feels we would be safer with an obstetrician in a hospital because of the complications of my past pregnancies and the difficulties we've had conceiving. I would like a midwife's opinion about whether or not I might be a candidate for homebirth and whether it is possible that a midwife would consider assisting us.

— Melissa

A: I suggest an invaluable resource that I discovered after experiencing a chemical pregnancy in May 2006. The book is called Taking Charge of Your Fertility, by Toni Weschler, MPH. The Web site is www.ovusoft.com.

Here's an overview of the book:

The book is written to help women achieve pregnancy, avoid pregnancy naturally, or be responsible for their health and lives. It explains how to achieve birth control without chemicals or devices, increase chances of conception or expedite fertility treatment by identifying barriers, help women choose the gender of their baby, and be personally in charge of sexual and gynecological health. The book includes an intuitive charting system; master charts, including charts for birth control, pregnancy achievement, and menopause; timely information about fertility conditions and treatments, and tables that summarize fertility-related drugs and procedures.

— Patrice London


Responses to any Question of the Week may be sent to E-News at any time. Write to mtensubmit@midwiferytoday.com. Please indicate the topic of discussion *and the E-News issue number* in the subject line or in the message.


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Think about It

Suddenly, I understood my aversion to birthing videos. If birth is sexual, then it should be private, and I don't want to be an observer. Sexual chemistry is a communication between persons. In the sexual event called birth, the parties are mother and baby, and both need privacy. Health workers attending the birth can offer the necessary expertise, but any other presence is not only gratuitous, but could also disturb the delicate chemistry between mother and baby.

Every woman must decide whether the baby's father or siblings are outsiders, and I would respect any woman's choice. But the debate about fathers attending birth often circles around the man's perspective. The argument in favor: He wants to be "part of it." The argument against: His sexual relationship with the mother may be adversely affected. The effect of his presence on mother and baby is surely the most important question.

Now I see the contemporary chorus attending the birth—and the photo and video displays before and after—as too much. When the baby's image has been shared with dozens before it is born, do parents lose a certain private knowledge, a sense of mystery? When the video camera is rolling, can the mother let her rational brain go?

Equally important, does the baby expect a crowd? The African proverb says it takes a village to raise a child. But does the village need to be on hand as the baby crosses the literal threshold into air-breathing society?

— Nina Planck

Editor's note: What do you think? Tell E-News readers about it by e-mailing mtensubmit@midwiferytoday.com.


Feedback

From my research into this area [when to begin feeding babies solids—see Issue 8:14], I understand that if a child has a family history of severe reactions, it may be best to put off solids for most, if not all, of the first year. It seems some children are ready for solids at five months and some are not ready until after their first birthday. We have, in our culture, an attitude that all children should develop at the same rate—birthing on the clock, growing at the same rate, and taking solids starting at four to six months. Nothing could be further from the natural order of things. Instead, we should probably do what are forebears did, which was to look to the child for signs of readiness: grabbing at food, hungry behavior, and general interest in food. Most baby foods have very few calories, so babies get their major caloric intake from breastmilk. Solids in the first year are there for sampling and variety, not for major calories, (although some children need some extra iron so I think you are probably right hedging with the vitamins). Your breastmilk will change to meet the needs of your growing child.

Karen Crow


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