For many years there has been growing concern about the culture of fear that is penetrating maternity services throughout the world, and that the fear felt by maternity care workers is directly and indirectly being transferred to the women and families they serve. The consequences of fear includes increased risk of defensive practice, where the woman and her family become potential enemies to those providing her care. In addition, the prevailing risk management and 'tick box' culture in maternity services encourages maternity workers to give priority to the records instead of the childbearing woman. These factors contribute to the dissatisfaction felt by those using and providing maternity services, and the apparent lack of kindness and respect. There is however increasing evidence that kindness, compassion and mutual respect improves efficiency, effectiveness, experience and staff morale within healthcare settings. The Roar Behind the Silence provides information, inspiration and practical suggestions to support maternity care workers, policy makers, and maternity care funders across the world in their quest to deliver sensitive, compassionate and high quality maternity services.
The book highlights examples of good practice, and practical tools for making change happen, using evidence and stories where appropriate. Edited by Sheena Byrom & Soo Downe, with contributions by Hana Ruth Abel, Maria Helena Bastos, Dean Beaumont, Dianne Bowser, Anna Byrom, Sheena Byrom, Penny Campling, Michael Clift, Hannah Dahlen, Raymond de Vries, Soo Downe, Ngai Fen Cheung, Julie Frohlich, Kathryn Guttridge, Jennifer Hall, Shelagh Heneghan, Milli Hill, Billie Hunter, Mavis Kirkham, Mande Limbu, Amali Lokugamage, Kerstin Uvnas Moberg, Mercedes Perez-Botella, Gill Phillips, Elizabeth Prochaska, Progress Theatre Group, Rineke Schram, Anna Ternovszky, Lucie Warren and Robin Youngson.
Only for the heartstrong
Olivia Armshaw
As one of the 7243 midwifery students in training in the UK (2012/13) (HoC, 2014), this chapter describes my personal journey into midwifery: through fear, curiosity and wonder; my own birth experience of compassionate midwifery care – to being a student. I reflect on navigating the current landscape of midwifery: its challenges and beauty, and how I feel about the future, including some ways to keep my heart strong, like self-compassion, mindfulness, outdoor swimming and Twitter.
Fear has a lot to answer for
Fear, in a sense, drove me into midwifery: looking for alternatives to the dispiriting brutality and sterility of birth portrayed on TV and the internet, and the infectious tokophobia narrative that seems to drain women’s strength and curiosity about our bodies and our selves. While the focus of caregivers appeared to be on trying to eliminate fear; of pain, of losing control, of a bad outcome, I felt that fear was a normal, inevitable part of the experience, that a more useful approach could be to embrace it, creating an environment where feeling afraid or ‘losing it’ was safe and accepted. Personally, I had experienced birth as a deeply transformative and liberating psychosexual happening, supported by midwives who encouraged me to follow my instincts and have confidence in my body, so I felt safe and unobserved in labour. I know first hand that a well-managed, woman-led birth has the potential to immeasurably enhance a woman’s life and sense of herself, heal past trauma on the body, and have lasting positive psychological effects. The converse can also be true: when birth is insensitively managed, clock-watched and interventionist, it can exacerbate existing trauma, or simply feel like medical rape (Kitzinger, 2012)
Approximately 85,000 women are raped on average in England and Wales every year (MoJ, 2013). Since the age of eighteen, when I was raped, I had buried feelings about the event until thirteen years later, when pregnant, I became consumed by an irrepressible rage. Hormones get bad press. They are blamed for women’s mood swings, and extreme feelings are often labelled as hysteria. Through my midwifery training I have gained a more accurate view of hormones: that they are highly potent chemicals controlling almost all aspects of our lives, influencing all bodily functions, basic and sublime (Godfrey, 2004). Hormonal changes and the impending transition to motherhood were catalyzing a deep shift in me, and an opportunity for healing. I planned my first birth at home, where I felt safe and in control enough of the environment to fully let go. I saw birth as an extension of my menstrual cycle and sexuality; an instinctive, hormonal process and I wanted it to be an intimate event. The midwife attended in quiet confidence, not dominating, directing or instructing me; but unobtrusively, respectfully keeping watch. When I felt like giving up, instead of: ‘no, you can’t give up’, she listened to me and helped me realize that giving up was not a more comfortable option. My first daughter arrived into the water, as I repeated the word ‘release’ inside my head. Her birth became the most meaningful experience of my life, and I felt transformed, in awe of my incredible human body. I loved myself. Pregnancy and ultimately birth enabled me to express, release and move on from toxic feelings locked in my body, reclaiming my body with the same intensity as I had lost it. I felt grounded in a deep respect, pride and confidence in my humanness. Through the healing power of birth and good midwifery, I moved on, got free – and found my calling, to boot. I had discovered the potential of pregnancy and birth to affect a woman, and the importance of facilitating it, as far as possible, to occur in a spontaneous unmanaged way, with the hormonal integrity and rhythms intact. I would like to be the kind of midwife who sets the environment for a woman to trust her instincts and have confidence in her body, so she feels safe to express herself freely and does not feel observed. For me, trust is a remedy for fear, and finding ways to engender trust in a woman’s own body is a key part of being a midwife – curiosity and wonderment too. It is tragic that women are not curious about our bodies and what we can do; only scared. When I try to unravel the deeper causes of our insecurity, it seems the objectification of female bodies and the sexism inherent in the media representation of women play a part, as well as the routine medicalization of pregnancy and birth.
Spontaneous labour in a normal woman is an event marked by a number of processes so complicated and so perfectly attuned to each other that any interference will only detract from the optimal character. The only thing required from the bystanders is that they show respect for this awe-inspiring process by complying with the first rule of medicine: nil nocere [do no harm]. Kloosterman, G., Dutch professor of obstetrics, 1982
My own experience of compassionate midwifery care, combined with a yearning for change in public perceptions of birth, and for the sense of wonder described above by Professor Kloosterman – formed the foundation of my student midwife journey. I had done a degree in Human Communication and Social Anthropology twenty years ago, and had worked in Brazil and the UK in a variety of creative and brand copywriting roles, around having my three children. Midwifery is an expression of love and political consciousness, combining health, wellbeing, and the nurturing of women, with human rights and feminism, and is part of women’s struggle for equality and control over our own bodies – all in one profession. I never thought the career change would be an easy journey, especially with a young family, but the course is unexpectedly demanding on every level, and transformation into a midwife more profound than I had imagined.
As I morph from third-year student into qualified midwife, I am increasingly concerned about the medicalized, institutionalized and fragmented way women are cared for in the NHS, which feels as if it is being dismantled in front of our eyes. I have had the privilege of working with outstanding mentors, who have naturally modelled compassion, respect and kindness, in a variety of settings: a freestanding midwife-led unit; an alongside birth centre; and a large industrial-sized obstetric unit – amalgamated from two smaller ones – where it sometimes feels that women are processed through labour and postnatal wards, with little time to develop trusting relationships. In early labour many women come into hospital and meet the triage system, not their own trusted midwife. Although we can work openheartedly to build rapport and trust quickly, it can feel like the best of a bad job, because we know that women have better birth outcomes with a known and trusted midwife (Sandall et al, 2013). The postnatal care situation is particularly worrying and I do not know how to give women the time and care they need, especially breastfeeding support, when there is such rapid turnover on the busy wards. The system seems broken and I feel powerless to fix it. I am profoundly grateful for my placements at the freestanding midwife-led birth unit in the heart of the community – which also has a 5% home birth rate (double the national average), where midwives work extremely hard to provide continuity of carer. These community experiences of getting to know women throughout their pregnancies have given me a feeling of true midwifery, and I am excited about caseloading women in this final year of training.
The report on the Mid Staffordshire NHS Foundation Trust Inquiry (Francis, 2013), which highlighted a shocking need to change our healthcare system, affected morale across the UK. For me this was compounded by a heart-wrenching article in the Independent (2014) by an anonymous midwife outlining her reasons for resigning, after a decade, from the job she loved. It could have been written by any number of midwives I know, who are frustrated and demoralized; who feel they cannot use their skills, but do not want to act as obstetric technicians (Ball, Curtis and Kirkham, 2002); or who are exhausted by what feels like dangerous skeleton staffing, the rise in the birth rate, the increasing complexity of pregnancies and social factors, and the lack of midwives to share the workload. The article shook me surprisingly deeply, making me question my commitment, the strength of my compassion, level of resilience, depth of my love, and the impact on my family – oh the irony of helping women transition to motherhood whilst reneging on my motherly duties!
I feel sad that genuine choice of care and place of care is not uniformly available across the UK, or indeed the world. In 2014 the future of independent midwifery swung precariously in the balance as lack of accessible affordable insurance for independent midwives meant they might be forced into extinction. On a bitter March morning we students, haggard from night shifts and travel to London, marched on Downing Street like suffragettes, with ‘affordable insurance’ placards, along with independent midwives, NHS midwives, doulas, mothers, fathers and children. Thanks to the tireless Save Independent Midwives campaign, a workable solution has been found and for now the way seems clear, so choice – albeit at a price – is safe.
On placement, it is my mission to find midwives who profess that, even knowing what they know now, would still choose to be a midwife; those that love it and would not rather do anything else, are solid gold and I magnetize towards them. At a hospital antenatal unit I attended on placement, I absorbed as much as I could from the lovely midwives there, who make every effort not to pathologize women, looking instead for ways to make things cosy and unmedicalized – they are so kind and just plain nice to the women. What struck me was their lack of differentiation between the women and each other, the midwives, doctors and students – just an air of respect and compassion for all: ensuring everyone had proper, timely lunch breaks and left work on time; making rounds of tea for each other; sharing the boring admin jobs; having a laugh even when clinics were overflowing, and no talk of blame. The unit manager is shiningly kind and I felt nurtured and cared for there.
In my final year of training, thanks to Iolanthe Midwifery Trust, I did an elective midwifery placement at Hospital Sofia Feldman in Brazil, an oasis of humanized care in an extremely medicalized birth culture: national caesarean rate of 50.1% (Leal, 2012); syntocinon drip and amniotomy used on 40% women; 91.7% of vaginal births are in lithotomy; 36.1% with uterine fundal pressure; 53.5% episiotomy (Leal, 2014), and 65.2% without birth partner during labour (Diniz et al, 2014). However humanization – synonymous with the Dignity in Childbirth and Respectful Maternity Care agendas (Birthrights, 2013; White Ribbon Alliance, 2011) – is gaining momentum, and Brazil, once famous for its high caesarean section rate, is now becoming known as the place where change is happening. Humanization is not just about lowering the intervention rate, but the simple addition of kindness, compassion and respect to our work, shown through eye contact, smiling, holding a hand, explaining and discussing options clearly, appropriately exploring consent, and including birth partners. These simple behavioural habits are how we make a difference wherever we are, yet I have noticed that when the pressure is on, they can be the first elements of care to disappear. I learnt so much from the Brazilians who are committed to supporting women to birth their babies in a gentle, physiology-enhancing environment; fighting to strengthen midwifery and end obstetric violence of all kinds. And although more extreme in Brazil, the principles of humanization are just as relevant in the NHS Trust where I work.
I feel like I am coming into midwifery with my eyes opened to a fairly bleak landscape in which midwives are longing to give the compassionate care we are trained for, despite the many factors blocking our way. The pockets of loveliness, shining midwives, movements for Normal, Better and Positive Birth; for human rights in childbirth, to save independent midwifery, and to embed the 6Cs into maternity services (Care, Compassion, Competence, Communication, Courage and Commitment) (DoH, 2013) – are all testimony to this longing, and I feel optimistic about the future. Mostly. I am concerned about how I will manage to uphold my ideals of compassionate care, keep the love flowing, build my own resilience, wellbeing and positivity, and not burn out.
I find solace and wisdom in Gilbert’s The Compassionate Mind (2009), which links self-kindness and self-compassion with well being and coping with stress. In the section on building the compassionate self, he cites mindfulness as the first step, that is, learning how to pay attention in the present moment without judgment. It is a way of understanding ‘attention’ and choosing to direct it to a particular experience or sensation – being in the moment (Gilbert, 2009).
After completing a mindfulness-based stress reduction course, I try to be mindful in practice, sometimes doing the three-minute breathing space in the toilet: a mini-meditation that can be used anywhere when things feel overwhelming or difficult, to feel grounded in the present moment again. It is a process of becoming more conscious – by noticing and acknowledging what is there in me, what is going on for me, what I am feeling, I am better able to be present to others, specifically who I am caring for. Beddoe and Murphy’s (2004) study of an eight-week mindfulness-based stress reduction course for nurses showed that their mindfulness practice facilitated empathic attitudes, as well as decreased their tendency to take on others’ negative emotions. Shapiro (2005) suggests the added bonus that such self-care trickles down to improve the quality of the therapeutic relationship.
Self-care is paramount. This is not just about taking breaks, keeping hydrated and having a laugh at work – but outside midwifery, it is essential to prioritize swimming; sleep; good food; time with my family, and friends if I am lucky. These things are not just ‘nice to have’, they are part of my survival kit and when I do not make time for them, I am much more vulnerable to mental and physical problems. I cannot be an authentically compassionate, energized midwife if I am exhausted, hungry, uncomfortable and stressed. Professor of human development and self-compassion expert, Dr Neff (2011) recommends that at any moment you feel challenged beyond your ability to cope, try giving yourself compassion, which might involve putting your hand on your heart to physically comfort yourself and say something nurturing and supportive to yourself (as you would to a close friend).
Last but not least: Twitter, the great community builder and network maker, has helped me grow as a student midwife, nurtured, sustained and educated by the connections and relationships I have made. It also provides a forum for activism, promoting normal birth, debating human rights in maternity care, the patriarchy, and the failings of institutionalized postnatal care – amongst many issues. Twitter provides a means to conserve energy and thrive, helping me to balance the bigger questions with my everyday interactions of care. I found my Twitter voice engaging in meaningful conversations with fellow students, midwives, midwifery elders, researchers, campaigners and healthcare practitioners. I have become part of a new feminism, exploring new ideas, schemes, policies, events, and conferences. I have been challenged and challenged others, made great friends and found new people to admire and learn from in the nourishing ecosystem of midwives, doulas and obstetricians on Twitter, which is helping me develop as a post-modern midwife, globally conscious and connected (Davis-Floyd, 2007).
Our birth culture is driven by fear and blame, and I admit it: I am afraid of making serious mistakes; causing harm inadvertently; missing something important – not to mention the ever present spectre of litigation and loss of professional registration, before I have even achieved it. I hope that when I qualify I will be supported with a preceptorship, not left alone to deal with complex situations too soon. I hope that delivery suites will look like birth centres. I hope that postnatal care becomes valued so we have time to care. I hope more women choose to birth at home. I hope for more midwives. I hope I can keep my heart strong. I owe it to myself, my three daughters and their daughters, to generate a renewed trust and curiosity in our bodies, and respect and compassion for childbearing women, and midwives (ARM, 2013).
KEY MESSAGES
Compassion plays an essential part in woman-led care, which can enhance a woman’s life and sense of herself, and have lasting positive psychological effects.
Concern about a medicalized, institutionalized and fragmented maternity care system being inconducive to compassion, kindness and respect, as women feel processed through the busy wards, with little time to build relationships with midwives.
Committed, determined midwives strive extremely hard to provide the care we are trained to give, in spite of exhaustion, dangerous staffing levels, fear of litigation, low morale and pay freeze. But at what cost to ourselves, our health?
Cause for optimism: the strength and love of midwives; the movements for Normal, Better and Positive Birth; for human rights in childbirth, to save independent midwifery, and to embed the 6Cs into maternity services (Care, Compassion, Competence, Communication, Courage and Commitment).
ACTION POINTS
Consider using mindfulness as a way to help yourself, and others.
Join Twitter and start connecting with the global midwifery network.
Prioritize self-care: sleep, balance with family life, exercise, and nourishing healthy food.
Become a notes ninja: paperwork and computing are only going to increase, so if we students and new midwives focus on becoming speedy, accurate and subtle – so women don’t feel it’s our main focus – then we will have more time to be with the women.
Be compassionate to yourself.
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