After forty-one years of midwifery practice, the last 8 in New Zealand where many acknowledge that maternity care  is in crisis, I have created a petition that respectfully requests that the New Zealand Ministry of Health:

• Develops an accessible, practical campaign to promote, support and protect natural or physiological birth throughout New Zealand.
• Widely publishes data on all New Zealand place of birth outcomes to foster informed maternity choices.
• Provides dedicated funding to ensure equitable access for well women to local community oriented, physiologically appropriate and culturally sensitive primary birthing units.
• Publicly promotes, encourages and supports birth at home with experienced midwife for well women.
• Engages with women, their whanau and national media as well as representatives of all maternity care providers toward achieving the aforementioned goals. 

Background Information.

1) Normal Labour and Birth.

Only one-third (33.2% or 19,646) of birthing women in 2014 had a normal birth according to the Ministry of Health’s (MOH) annual report. This was the first time a definition, and any information about those who have “a spontaneous vaginal birth without an induction, augmentation, epidural or episiotomy”; have been included in these reports. Rates varied according to maternal age, socioeconomic status, ethnicity, location and whether it was a first or subsequent birth. For example, as in other parts of the world the more well-to-do women had fewer ‘normal’ births than their more deprived sisters and women in some rural regions,

An understanding of the rates, impacts and influences on ‘normal’ birth, are important in assessing the quality of a service, and accounting for the cost of that service.  Normal labour and birth consumes less of a nation’s health resources, personnel, equipment and hospital beds.

Mothers who experience ‘normal’ birth are more likely to feel positively about their labour and birth, to bond more easily with their newborn, and to have less difficulty establishing breastfeeding. Thus birth and its consequences can provide psychological, as well as physical benefits for the woman, her baby, whanau and community. However, local surveys, articles and international studies reveal that for many women birth is traumatic and there is a lack of funded support services for these women. In addition, suicide is the leading cause of maternal death in NZ, and other countries, therefore maternity service providers need to consider the potential psychological as well as physical impacts of their policies and the information they offer women.

As, UK Professor Soo Downe says; “Most women, in every country across the world, would prefer to give birth as physiologically as possible. For most women and babies, this is also the safest way to give birth, and to be born, wherever the birth setting. If routine interventions are eliminated for healthy women and babies, resources will be freed up for the extra staff, treatments and interventions that are needed when a laboring woman and her baby actually need help. This will ensure optimal outcomes for all women and babies, and sustainable maternity care provision overall”.

Thus, in addition to meaningful definitions, the UK, Canada and other places have campaigns to improve rates of ‘Normal Birth’, and programmes to lower interventions, such as surgical deliveries. The UK “Campaign for Normal Birth” is a practical, accessible and evidence based effort, developed and supported by a broad range of maternity professional and user organisations including the Royal College of Midwives, Royal College of Obstetricians and Gynaecologists (RCOG) and the National Childbirth Trust. It has now morphed into the Better Births campaign.

New knowledge about our Microbiome, its development, and Epigenetics show that we are yet to learn the full implications, and costs of interventions in labour. Though rising each year, the levels in New Zealand are on the lower side of the middle range for most interventions in comparable countries.

2)  Impacts of Hospital Birthing.

Currently, the majority of NZ women labour and deliver in hospitals; 87% in 2014, despite extensive research on the adverse impacts of hospital settings, procedures and staff on natural labour and birth. Medical interventions are often unrelated to the health status of the woman.  Also, the rates of most childbirth interventions are happening at ever increasing rates each year, for example 25.9% of all births in 2014 ended in a Caesarean section, up from 23.3% in 2003.

The UK Birthplace Study shows that natural, satisfying birth is most likely to happen at home or in a free-standing birth centre or primary unit. NZ research on birth outcomes, confirms that this is also true here. There is a lot of evidence which shows that where a woman labours and births has a dramatic effect on intervention levels such as induction of labour [1], [2], [3], [4]. Evidence also indicates that when healthy women labour and birth in hospitals, compared to being at home or in a primary birthing unit, they have increased rates of interventions, even when they have continuity of carer [5], [6].

Though the levels of childbirth interventions are universally higher in hospitals, the perinatal or ‘around birth‘ mortality or death rates, are similar for low risk women at home or in a birth centre [8], [9]. Likewise being born in a hospital, rather than a birth centre does not necessarily improve mortality outcomes for babies. Internationally, as well as in NZ, healthy or low risk women report higher satisfaction with their birth experience in “home‐like” environments, compared to those who labour in hospital settings [10].

The July 2011 Expert Advisory Group report of the RCOG said; “Too much care is provided within secondary and tertiary settings. Too many babies are born in the traditional ‘hospital’ setting. We need to drive this care back into the community with the appropriate provision of facilities and professionals with appropriate skills.”

The majority of women in New Zealand, 93.7% in 2014, were cared for by a midwife Lead Maternity Carer (LMC). Also in 2014, 87% of all births occurred in hospitals where interventions happen, even in the births of healthy first time mothers. These facts suggest that many midwives need to re-learn the knowledge and skills involved in supporting out of hospital birth. A maternity system that promotes primary birth options and normal outcomes would increase midwifery satisfaction and retention rates, as well as improve the wellbeing of women and their whanau.

Also, in the UK there is a website to inform women of the outcomes for each birthing unit across the nation. Although there is no NZ equivalent, a post-graduate midwife is creating an ‘App’ for women about the outcomes of birth places here. A study in Iceland shows that “Efforts to de-stigmatise out-of-hospital birth and de-medicalize women‘s attitudes towards birth” increase women׳s use of health-appropriate birth services.

2.1) Primary Birthing Units (Birth Centres).

Recently,the National Institute of Clinical Excellence (NICE) said that midwife-led care has been shown to be safer for women and recommends that all women with low-risk pregnancies should be advised that giving birth in a midwifery-led unit, is “particularly suitable”. Here in Aotearoa, studies have also found improved outcomes for mothers and babies when a woman labours in a primary unit, compared to similar women who use a hospital.

Increased understanding of the impact of environmental factors on labour and birth, confirms the findings of UK surveys of women about factors which aid or hinder labour progress. These elements have been incorporated into the Mind-Body-Spirit Architecture of Bianca Lepori to create spaces which best support physiological labour and birth [12]. This knowledge has been used to develop the Birthing Unit Design Guideline, which is being applied in the rebuilding or refurbishment of many maternity units throughout Australia.

Studies show that Birth Centres (or Primary Units) can:

• address social exclusion by creating an open, flexible and accessible non-judgmental approach to care.
• build communities by forging links with parallel agencies.
• enhance recruitment and retention of midwives through increased job satisfaction.,
• encourage partnership and multidisciplinary efforts by working in the community [13].

Creating local birth units which are appropriately designed, community oriented, family-friendly and culturally sensitive across NZ would achieve all of the above, as well as be consistent with government programmes such as Whanau Ora and integrated health centres. However, development of such birthing units in Wellington, Dunedin, Palmerston North and Waitemata has not happened, despite various campaigns. A private company who recently opened a ‘birth centre’ in Bethlehem is building others in Palmerston North and Melling (Lower Hutt). Sadly these units appear to lack community consultations and connections.

Meanwhile, in other parts of the country, many older, community-based primary units are under-utilised, as women travel further to be delivered in hospitals, believing this is their ‘safest’ choice. Sadly, low occupancy has resulted in closure for some of these units, despite public campaigns to keep them open, as DHBs yield to short-term financial constraints. Hawke’s Bay hospital now has a new primary unit in the grounds of their hospital, in place of another older, remote one. However, evidence shows that units alongside obstetric facilities have higher transfer rates and therefore more interventionist outcomes compared to stand alone or free-standing birth units.

Thus, some DHBs inadvertently encourage all women to deliver in hospitals, such as in Waikato where a reduction in local birthing units is happening whilst Hamilton will lose 22 under-paid LMC midwives before next year. NZ midwifery is suffering with increased demands on all but particularly on low paid, poorly resourced, under-appreciated and sadly many unsustainable LMC practices.

2.2) Homebirth.

In the UK, there are campaigns by the national health services and parliaments of UK countries to increase homebirth rates, including as part of local health strategies. The RCOG publicly supports homebirth, stating: “The review of the diverse evidence available on homebirth practice and service provision demonstrates that home birth is a safe option for many women.”

Similarly in Canada, medical groups acknowledge the growing evidence showing homebirth with a midwife is a valid birth option for well women [14]. A recent West Australian government review confirmed there is “no evidence of adverse outcomes associated with planned home birth in low risk pregnancy”.

Here, in NZ, homebirth rates have been around 3% for the last decade, involving mostly older women, Maori and European, as well as some in rural areas. Home Birth Aotearoa has gained government funding to share their knowledge and experiences about the safety and benefits of birthing at home with a known, experienced midwife. Still support for homebirth midwives from DHBs is variable, often minimal and usually involves a fee. Other than an infrequent statement  there is no obvious MOH or DHB supports or promotions, although studies are showing that homebirth is safer than hospital. Research shows that home is where natural birth is most likely to happen, leaving mother, baby and family in optimal psychological and physical health, thus homebirth is where health dollars and resources can be saved in the short and longer term. A 2012 Cochrane Review concluded that, “all countries should consider establishing proper home birth services. They should also provide low-risk pregnant women with information enabling them to make an informed choice.”

In recent decades, knowledge, understanding and experiences about physiological or truly natural birth have revealed how labour hormones work when a healthy woman in a nurturing and supportive environment is disturbed as little as possible. Ongoing respectful, quiet support of skin-to-skin contact, and possibly the first breastfeed, enables placental separation and birth, as well as minimising maternal blood loss, because undisturbed hormones peak after birth of the baby. Not clamping the umbilical cord before it has stopped pulsating, gives the baby back all its blood volume and nutrients, assisting its transition to extra-uterine life and optimal development.

Sadly, most NZ doctors, other health professionals, managers and many midwives have only experienced disturbed, managed, fraught hospital deliveries and so, like most of the population have some fear of natural childbirth, or Tocophobia in its extreme form. In the UK, Tocophobia is recognised as a contributor to and consequence of our birthing culture, so it has informed new maternity policies and campaigns there.

Finally though there is some internet leakage of positivestories on homebirth and midwives from UK news sources, this is not generally the direction of NZ based maternity news reports. Overall there is a complementary need for the NZ government to redress the national under-valuing of midwives and unbalanced media which contributes to a lack of trust in normal birth and midwives, and perpetuates the myth that hospital is always safer.

As UK Midwife Sheena Byrom in her most recent blog titled ‘Normal Birth – a moral and ethical imperative’ said “Promoting normal birth while also maximising the wellbeing of mother and baby is therefore not a cult, or a professional project, or a conspiracy. It is a moral and ethical imperative, that should be supported by all of those with any interest in the wellbeing of mothers, babies and families, in the short and longer term. This includes professionals, journalists, politicians, health service managers, childbirth activists, and lawyers”

Numbered References.

[1] Solomon, J. ‘New Zealand Research on Place of Birth’, Women’s Health Update, Vol 12, No 1, January, pp. 1 ‐ 2.

[2] Earl, D. Hunter, M. 2006 ‘Keeping birth normal: midwives experiences in a tertiary obstetric setting’, New Zealand College of Midwives Journal, Vol 34, April, pp. 21 – 23;

[3] Hodnett, ED. Downe, S. Edwards, N. Walsh, D. ‘Home‐like versus conventional institutional settings for birth.‘ Cochrane Database of Systematic Reviews 2005, Issue 1, Art. No: CD000012. DOI 10.1002/14651858.CD000012.pub2.

[4] Skinner, J. Lennox, S. 2006 ‘Promoting normal birth: a case for birth centres’, New Zealand College of Midwives Journal, Vol 34, April, pp. 15 – 18.

[5] Davis, D., Baddock, S., Pairman, S., Hunter, M., Benn, C., Wilson, D., Dixon, L. and Herbison, P. ‘Planned Place of Birth in New Zealand: Does it Affect Mode of Birth and Intervention Rates Among Low-Risk Women?’ Birth, no. 10: 1523-536.

[6] Miller, S. 2009 ‘Are midwives more ‘at home’ at home?’, Birthspirit Midwifery Journal, Issue 1, February pp. 7 – 11.

[7] Olsen, O. 1997 ‘Meta‐analysis of the safety of home birth’. Birth, Vol 24, No 1, pp. 4 – 13.

[8] Olsen, O. Jewell, MD. 2000 ‘Home versus hospital birth’, Cochrane Review. In: the Cochrane Library, Issue 2, 2000. Oxford: Update Software.

[9] Smythe, L. Payner, D. 2008 ‘Warkworth Birthing Centre: an appreciative inquiry’, AUT University.

[10] Earl D, & Hunter, M. (2006). ‘Keeping birth normal: midwives experience in a Tertiary obstetric setting.‘  New Zealand College of Midwives Journal 34,21-23.

[11] Fahy, K., Foureur, M. & Hastie, C. (2008). “Birth Territory and Midwifery Guardianship. Theory for practice, education and research.” Books for Midwives Elsevier.

[12] Kirkham, M. (2003) ’Birth Centres; A social model for maternity care.’ Books for Midwives, UK.

[13] de Jonge A, van der Goes B, Ravelli A, Amelink-Verburg M, Mol B, Nijhuis J, Bennebroek Gravenhorst J, Buitendijk S. ‘Perinatal mortality and morbidity in a nationwide cohort of 529 688 low-risk planned home and hospital births.‘ BJOG 2009.

In the ‘Forward’ legendary, USA midwife Ina May Gaskin encourages us all by saying that the amazing outcomes of this program can be replicated anywhere “the needs of birthing women are put before other concerns which often enter into maternity care policy-making and practice”. Ina May also challenges midwives, their educators and regulators by saying that the ‘true art of midwifery’ as shown in this book, is to reduce or eliminate fear of birth.

Author, midwife Becky Reed puts the contents of the book in the framework of her maternity history, midwifery career and history in the introduction; “Looking at birth”, as the birth of her first child is the first story of this tome. Her first child was a hospital birth in 1979, illustratings some of the changes in maternity practices since then. However, too many birthing women are still put in a semi-recumbent position despite evidence of the negative impacts on both mother and baby, as well asbeing contrary to the preferences and instincts of women to adopt a more appropriate, supported upright or kneeling position, as demonstrated in the other stories in this book .

Photos in the book were created as Albany midwives carried a camera as part of their birth kits, and women gave them back some of their birth photos to use as part of the 36 week “Birth Talk” for other women on the program. Subsequently many program women thought the use of photos as part of their ‘Birth Talk, “helped them to believe in themselves”. In addition, birth photos were a feature of the settings where the program’s women-led antenatal and post-natal gatherings were held, which often provoked questions and enhanced discussions at these events.  Positive responses to a ‘photo story’ series of articles by Becky in ‘The Practicing Midwife’ encouraged her to create this book. Becky also felt that pictures of labour and birth need to be accompanied by their stories to give them additional meaning and educative value, which is lacking in birth photographer’s web sites and You Tube uploads. Despite the constraints of non-professional photographers (midwives or family members), limited light, tight spaces and often awkward positions of the subjects the photos show the dynamic character of natural labour for each woman. Also demonstrated in these pictures are features of physiological birth rarely seen in hospital deliveries, such as a baby born in its caul, vaginal breech birth, cords left to finish pulsating and women birthing their baby’s placenta.

Currently the majority of midwives and other maternity care practitioners qualify and practice in environments which do not promote, encourage or support physiological labour or birth, and thus such maternity professionals have not seen, nor experienced enough natural labours or births to have developed the skills and confidence to ‘manage’ woman wanting a natural labour and birth, especially outside a hospital. For example, most hospital trained midwives do not feel confident assessing progress of labour through visual and auditory signs or ‘allowing’ women to push on their own initiative as in these stories, rather they rely on disturbing the woman’s rhythm to do a vaginal examination(s). Therefore this book adds to the published research which shows us that use of inappropriate birthing spaces and practices contributes to the escalating rates of childbirth interventions, particularly  for healthy women.

The stories and pictures in this book show women being cared for by midwives who encourage and support physiological birth as a normal life event in familiar, respectful and private environments; women who are trusted to make healthy choices for themselves and their babies. It shows that birth can be normal, healthy and joyous whether it happens at 36  or more than 42 weeks; whether a first or a seventh baby; a baby coming head  or bottom first, or being followed by a twin. Thus this is an essential  book for the reading lists of Child birth Educators, Schools of Midwifery, all Midwives and Obstetricians as well as women’s groups!

Addition: Finally an analysis of the outcomes of this program is available here and show that;

• Though more than half (57%) of all women were from minority ethnic communities; one third were single and 11.4% reported being single and unsupported. 
• Almost all women (95.5%) were cared for in labour by either their primary or secondary midwife. 
• Resulting in high rates of spontaneous onset of labour (80.5%), spontaneous vaginal birth (79.8%), homebirth (43.5%), initiation of breastfeeding (91.5%) and breastfeeding at 28 days (74.3% exclusively and 14.8% mixed feeding). 
• Of the 79% of women who had a physiological third stage, 5.9% had a postpartum haemorrhage. 
• The overall rate of caesarean section was 16%. 
• The preterm birth rate was low (5%). Ninety-five percent of babies had an Apgar score of 8 or greater at 5 minutes and 6% were admitted to a neonatal unit for more than two days. 
• There were 15 perinatal deaths (perinatal mortality rate of 5.78 per 1000 births); two were associated with significant congenital abnormalities. 
• There were no intrapartum intrauterine deaths.

Currently in New Zealand where more than 90% women do choose a midwife as their LMC only 3-4 % of births per annum for more than the last decade, have been at home. Meanwhile as elsewhere, rates of intervention (as below) in the labours and births of healthy women have escalated, as more and more women labour in hospitals (87% in 2014) whilst numbers who use primary units (‘birth centres’) has declined to 9% in 2014.

The NZ Ministry of Health’s definition of a Spontaneous Vagainal delivery is “any vaginal birth that does not involve Obstetric assistance or delivery’ and in 2014 did include;

• 24.4% ARM or Artificial Rupture of Membranes, from 19.0% in 2005, though the membranes protect both mother and baby in labour,
• 24% Induction of Labour  or IOL;  despite the risks,
• 26% Augmentation of Labour despite lack of accuracy in assessing progress of labour
• 27% Epidural despite the potential for care to raise beta-endorphin levels
• 15% Episiotomy compared to other means to protect the perineum.

These statistics means  that 1 in 2 women had some form of intervention in their labours resulting in possible separation of mother and baby, especially for the 25.9% who ended their efforts with a Caesarean section . This is all despite local research which have similar outcomes as the UK Birthplace study, showing that home and birth centre births result in the healthiest outcomes for mothers and babies.

Meanwhile The Midwifery Council NZ is “The Guardian of Professional Standards” says that “The competent midwife …………………….utilises midwifery skills that facilitate the physiological processes of childbirth and balances these with the judicious use of intervention when appropriate”.

“Why not Home?:The surprising birth choices for doctors and nurses” 

The interviews in this film; of the health professionals, their caregivers and partners reveals practical and emotional reasons why they chose to birth at home rather than in a hospital, but none mention the negative impacts of the external and, or internal environment of labour, on the production of the birthing hormones; Oxytocin, Endorphins, Adrenaline/Noradrenaline and Prolactin. Nor do any of the additional maternity experts even suggest that the flow of vital substances like Oxytocin,“the shy hormone”, can be helped or hindered by environmental factors such as bright lights, noise and activities including care-giver practices or a labouring woman’s fears and behaviours. All these factors can block a labouring woman’s ability to make the essential birthing hormone cocktail and thus labour stalls in all sorts of environments but especially in unfamiliar hospitals where bright lights and noises are common along with the all hours monitoring and treatment of their ‘patients’.

The labours and births shown in this film are very similar to those which result in hospital vaginal deliveries in New Zealand, with the women mostly in positions that permit a midwife or doctor to ‘deliver’ the baby and immediately lift the baby onto their mother’s chest. This hands-on, directive style contrasts that of homebirth midwives I work with, who encourage women to birth their babies in the way that facilitates the mother’s “Fetus Ejection Reflex” and the efforts of their baby to be born. This can happen when  labour is disturbed as little as possible and the woman is confident, connected and works with her baby and body birthing instinctively as nature intends. For labour and birth to be an involuntary, instinctive process, the environment and all present during labour and birth need to protect, support and encourage the flow of birth hormones which orchestrate the ‘dance’ between mother and baby. Such natural or physiological birth is most often achieved when women, like other creatures nest, hence the better outcomes and greater satisfaction of women who birth at home compared to those who have more disturbed or managed labours and deliveries in hospital.

Not shown or discussed in this film is the natural option of gentle, spontaneous birth of the baby’s placenta, which usually results within half to an hour after the baby’s birth when this transition period is undisturbed, so the hormones flow optimally to complete the birth process. However I suspect that the women in this film had active management of this ‘stage’ including an injection of synthetic oxytocin followed by clamping and cutting of the cord before it had ceased its pulsations. Active management or placental delivery is done “to reduce bleeding” however statistics and experiences of  hands-off midwives is showing that when nature is supported and protected mothers bleed less and babies retain most of their (uterine) circulation making them optimally healthy for life outside the womb.

New Zealand women, unlike those in the USA have access to continuity of care by a midwife, and this is one of many countries in the world who have better infant and maternal mortality rates than the US. However, New Zealand birth outcomes do not support the expressed belief of Prof Eugene DeClerq “that wider use of midwifery” is the single change needed to address rising rates of caesarean section. Here in New Zealand over 90% of women have continuity of a care by midwife through pregnancy, birth and afterwards, yet from 2009 to 2014, as in previous years, there has been an increase in the rates of Caesarean section, and other interventions with no correlation with increased clinical need. For example healthy first-time mothers, with no obstetric indications, aged 20–34 years old, in labour at term (37–41 weeks) with a single baby, presenting head first, have had a decrease in spontaneous vaginal births from 2009 to 2014. In addition, the latest and previous annual MOH report shows that the vast majority (87%) of women gave birth with their midwife at a secondary or tertiary maternity facility, whilst only 3% birthed at home.  Also, half of all New Zealand women who birthed in 2014,  mostly in the care of a midwife and in a hospital, had at least one form of intervention during their labour and, or birth (24% – induction, 26% – augmented labour, 27% –  epidural, 15% – episiotomy).

The national caesarean section rate in 2014 was 27.4%, but 17.8% in 1999 when New Zealand women were first able to choose government funded maternity by the midwife of their choice. This rate was highest amongst women from the more affluent neighbourhoods who again would have a lower clinical need. Also, outcomes for women and babies varied between district health boards (DHBs) and between individual hospitals, all of which is consistent with the explanation in the “Why Not Home” film that; what practitioners experience influences their ‘world view” and what they professionally do and believe!

The women and community of New Zealand are generally unaware that local research indicates “that for women having a second or subsequent baby, home births and midwifery unit births appear to be safe for the baby and offer benefits for the mother”. as reported by the UK Birthplace study, UK media, and supported by the Royal College of Obstetricians.

The Ministry of Health, Royal Australian and New Zealand College of Obstetricians, Midwifery Council and College of Midwives need to explore and act on last year’s research by New Zealand born and now ex-pat Dr Sarah Buckley about the evidence on innate hormonally-mediated physiologic processes in women and foetuses or newborns during childbearing, and possible impacts of common maternity care practices and interventions on these processes, focusing on four birth hormones.

Finally the world would  benefit from a Kiwi centred documentary which examines all the options, knowledge and issues of “Why Not Home In New Zealand?”

In her “Forward, forewarned….” Kate acknowledges she has left out men, and their perspectives on these things, and that she refers to the unborn child as ‘them’ because she feels “we need gender neutral language, particularly when discussing the baby in the womb, whose person-hood can be felt before their sex can be identified.” Next comes the first of Kate’s “pick-your-own adventure moment” pages, where the reader can choose how to navigate this book according to whether they want to, in this instance on page 10; “find out how to make a baby” or not. Also through-out this book, Kate is a dispeller of fairy-tales, a realist, for example on page 29’s “pick-your-own adventure moment” she acknowledges that there are at least 6 different ways that today’s woman may have obtained sperm; not all loving nor human.  I wish I could have used this book as a guide to exploring my cycle, “fruity juices” and nature’s conspiracy to aid penetration of one ‘Lily of the valley’ smelling ovum by a single, “hyper-fast wonky swimming sperm”. Kate Evans also shows herself to be an inclusive feminist in her drawings and text, which acknowledge different racial and sexual identities, such as in the brief segment titled ‘Breeders and non-breeders’ she says we all need to respect that some women do not want children and that there are other paths including for those who are gay, straight or bi-sexual, some of whom may benefit from the practical information offered about understanding our bodies’ fertility, regardless of whether our cycles and lives are ‘regular’.

“Medicine man vs Witch doctor” on page 68, is the first example of another of Kate’s themes in this book; the critiquing of Western medicine’s limited efforts to support “our bodies’ efforts” to reproduce. In comparison, this book offers an holistic, ecologically sustainable and physiological approach to fertility and childbearing, with info-graphics on complementary therapies such as acupuncture, inclusion of varying emotional states in the “Things that go bump” chapter (p 154) to “The psycho-bitch-from-hell feeling”(p 84), as well as practicalities; like explaining how to connect with one’s ‘Butterfly kissing baby in the womb, other than through scans (page 147) to The broke mum’s budget baby list” section (p 176) . In addition, Kate’s sensitive realism shines through in her efforts to address critical matters such as partner abuse; where she acknowledges the difficulties women have in accepting or leaving a relationship which was thought to be born of ’love’, but is in-fact toxic for herself, her baby and sadly could become lethal in a culture “which romanticise arrogant emotionally unavailable men, which blame women for being victims.” Chapter 13 “Ask Aunty Katy” (p 195) is the epitome of this book’s relaxed, girl-friend style and efforts to show that many of today’s fears have in fact a good news element to them such as “There’s a reason for the anatomical proximity of anus and birth canal and, If you can get through the birth of your child without simultaneously throwing up and wetting yourself, you’re doing better than me”.

Readers outside, and possibly inside of the UK, probably need references, which indicate safe bed-sharing is supported by the UK Baby Friendly Hospital Initiative and National Institute on Clinical Evidence (NICE) as well as backed by UK and international research, attached to, or inserted into the info graphic on it (p 177).

One New Zealand reviewer of this book suggested that Chapter 15; “Crossing the sea” should be a pull out frieze for women in early labour”. As a midwife I appreciate the woman to woman encouragements and entreaties to go forth into labour and birth; “To remember your baby loves you. Close your eyes and journey in your mind to somewhere beautiful with your baby. Talk to your baby, tell them it is time to come through.” It is unique and invaluable that birth is presented as “what has happened when women have had babies since time immemorial” (p 227), usually without men and not in some-one else’s domain, so it would seem like Kate is promoting homebirth for those who only know hospital as where to be delivered. It is also vitally important that this account includes an understanding of the labour and birth hormones, as well as the factors which can enhance or limit their working, as a key ingredient in the unfolding process. It is fitting that legendary English Midwife Mary Cronk is the model for Kate’s wise-woman, knitting midwife, as Mary has helped midwives all over the world retain the knowledge to support and assist the natural birth of all babies but especially twins and breech babies. Her crone encourages the ability of Monkey Mamma’s inner, ancient mammalian brain to send out hormones which make the womb-work till the last act of procreative genius whereby the living ligatures of her womb births the placenta and stems bleeding. This chapter’s pace, content and tone are a contrast to the next; “Totally Bananas, which, though it begins a little confrontationally; “Who put men in charge of childbirth? I mean honestly, what was that about?” , it is actually an evidence based and historical review of medicalised childbirth. Thereafter follows less emotive sections on the physiological needs of labouring women, different maternity systems, women’s “Birth rights” and other birth options including a positive caesarean section (p284).  The book ends as it began with another cherubic baby, though this time in the form of another of Kate’s info-graphics; the “New centre of the Universe”. Follow this link to  a full and significant chapter; “How monkey Mama does it!”, which is Kate’s pictorial explanation of truly natural birth.

I think the disclaimer and entreaty that “this book doesn’t have all the answers, but it might inspire you to further research” would be more appropriate as part of a separate section titled ‘Further Reading”, rather than placed at the beginning of the ‘References and Index’. This is because there is a lot more information, as well as international, national and local support groups for issues addressed in this book, which readers could have been encouraged to Google. However, overall I am thankful that someone has put humour, emotions and fact in such a delightful package for women and their midwives, and I would like to see this book on the reading lists of all Childbirth Education and Midwifery courses.

Denise Hynd
Midwife

A midwife explains labour and birth from a baby’s perspective!

The knowledge about how to give birth is within every woman.

The knowledge about how to be born is within every baby.

Labour is an instinctive dance between mother and baby !

Birth is a ‘pas de deux’!

In Pregnancy.

Authorities are beginning to acknowledge that parenting begins before birth, and possibly before pregnancy. There is mounting evidence from scientific experiments, and personal stories of children and adults about their experiences before birth, which makes us realise that memory, learning and communication begin in the womb; a long time before we acquire language. Babies in the womb have a fast developing sensory system which allows them to react to individual voices, stories, music, and even simple interaction games with the mother from about the second month (8 weeks) of pregnancy.Therefore the quality of the emotional, as well as the physical uterine environment is affected by the parents, their behaviours and their lives.

Most women become aware of their baby’s movements from about 16 to 22 weeks of their pregnancy, depending on various things like; is this their first baby or not, is the placenta at the front of the uterus which may also be well covered with fatty layers, both form padding which can lessen the sensation and awareness of baby’s movements. These days many women do not notice the time of the first, or subsequent movements as they are busy working long hours, this lack or late perception maybe a sign that a mother needs to slow down, rest so she can connect with and nourish her baby, to help it grow emotionally, as well as physically. Those who study stillbirth in Australia and New Zealand, encourage mothers to be mindful of their baby’s behaviours, advising that as the baby grows the number and types of movements will change depending on the mother’s activity. They also warn that “a change in the number or pattern of movements may be an early sign that the baby is unwell and should be checked” with their maternity care provider, rather than waiting for the next appointment or monitoring. Sleeping on her left side during the last weeks of pregnancy will also helps to nourish and maintain its growth by not compressing her blood vessels which give the womb and baby its blood supply. Drugs like smoking, alcohol and strong pain killers are known to alter a baby’s behaviour, and this is why we need to decrease the exposure of pregnant women to noxious substances such as car fumes and cigarette smoke.

During the Birth Process

In labour, the baby is not a passive passenger but rather an active participant in starting and progressing their births, as seen in this graphic. Mothers, who are encouraged  to find positions that assist their baby’s decent through the pelvis, for example by using opening movements such as hip gyrations, lunges or squatting rather than reducing their outlet by sitting on their bottoms, have easier and more fulfilling births. Birth environments which have low lights, low noise and privacy also enhance the birth efforts of both mother and baby by aiding the production of labour hormones; morphine-like substances or Endorphins and the “love hormone” or Oxytocin.

Leaving the cord connection between baby and mother after birth, until it has stopped pulsating not only aids the baby’s immediate transition to life outside of the womb but results in a baby who is not anaemic at 6 to 12 months of age, unlike those who have this link broken earlier. Skin-to-skin contact between mother and baby after birth “stabilizes the newborn’s first breathing efforts and oxygenation, increases glucose levels (reducing hypoglycemia), warms the infant (maintaining optimal temperature), reduces stress hormones, regulates blood pressure, decreases crying and increases the quiet alert state.” Initial Skin-2-skin contact between mother and baby also helps  long term maternal efforts of  breastfeeding, settling and a host of interactions with baby by the best foundation levels of that “Love” hormone; Oxytocin.

In Infancy

Long term benefits of maternal closeness with her baby are not limited to infancy or childhood.  Many studies since John Bowlby in the 1950s, have shown that the mother-child bond is the essential and primary force in infant development; this knowledge is the basis of attachment parenting practices such as baby-wearing and elimination communication or baby-led toileting. All babies are naturally hard-wired to expect unity with their mother, and for that unity to continue after birth. “Birth no more constitutes the beginning of the life of the individual than it does the end of gestation. Birth represents a complex and highly important series of functional changes which serve to prepare the newborn for the passage across the bridge between gestation within the womb and gestation continued out of the womb.” (Montagu, 1986, 57) The mother-baby partnership sets the foundation for other relationships in life, as birth and breastfeeding are peak times of Oxytocin production; the hormone of human connection and socialisation as well as love.

The national Brainwave Trust, who are sponsored by the Ministry Of Social Development, are one of many renown bodies who explain to the New Zealand public that during the first year of life, the quality of a child’s primary attachment affects right brain growth.  he right side of the brain is responsible for processing information related to our social interactions and emotions. For the primary or first attachment to be effective in this role it requires; “the consistent interplay of a highly complex and sophisticated, but purely emotional, communication to occur between the primary caregiver and the child. Studies have demonstrated that the manifestations of right brain growth and development that occur within the first two to three years can last a lifetime and security of the attachment bond is the primary defence against trauma-induced psychopathology (Schore, 2002)…Research has shown that children who do not develop secure attachments with a primary caregiver during the first years of life later are unable to calm themselves down; they are more likely than are secure children to overreact to stimuli. Insecure children have less impulse control, less ability to tolerate stress, and less ability to tolerate frustration than do individuals who have experienced a more secure childhood (Toth & Cicchetti, 1998).
The presence of a maternal figure has been shown to reduce childhood pain and distress in unfamiliar environments and aid healing, thus most children’s hospitals world-wide, support and encourage a primary carer of hospitalised infants and older children to room-in with them 24/7. Similarly, the knowledge that a disrupted mother-baby relationship can have long term negative health consequences for the child-as-adult, with ongoing costs for us as a community  is recognised by this government child protection agency’s statement that “To successfully ensure the safety, permanence, and well-being of children it really helps to be “attachment literate.” This means knowing what attachment is, how it works, and how to respond effectively to attachment problems.”

Conclusion.

We need to do all we can to promote, protect and support the mother-baby bond from conception into childhood and beyond, as it has life-long emotional and physical benefits for us as individuals and therefore for our families and communities.

The ‘greatest birth story ever told’ has a lot to teach 21st century policy makers, writes Milli Hill

© Getty Images

When it comes to giving birth, maybe newer, shinier and more technological isn’t necessarily better. The world was baffled recently when new UK guidelines for pregnant women stated quite clearly that hospital was the LEAST safe place to give birth – how very mysterious! Could it be that those beeping machines and vigilant docs, which we’d all been led to believe epitomised progress and were so very essential to our labours, were actually making things worse?!

It seems like the world is finally waking up to the fact that birth is something so fundamentally human – like eating, sleeping, making love – that it does not benefit from the interference of modern technology. With birth, we need to go back to basics, and to allow ourselves to be mammals. And so, although the straw might be a little spiky on the knees, a stable might be just the place to have a baby. Here’s why:

Privacy
OK, so there was an Ox and an Ass (we’ll come to them later), but it’s unlikely that Mary had to introduce herself again when the shift changed or talk through her birth plan with a dozen different strangers. This sense of privacy would have made her more likely to produce Oxytocin, essential to the progress of labour and birth, and often called the ‘shy hormone’, because it’s production can be hampered by interruptions. If you’re male or have never had a baby, this clip might help you understand how some bodily functions are very difficult under observation:

Darkness
No glaring electric lights in the stable, just good old-fashioned darkness – and the glint from an unusually large star, I’m told. But a dimly lit corner of a warm safe place just ‘feels’ right for all mammals. When wild animals give birth in captivity, their human carers go to great lengths to make a dark, safe space for them, understanding only too well that problems can arise if they are disturbed. As well as the privacy that darkness offers, it’s also all about hormones: in darkness we produce melatonin, and this works in partnership with other hormones like oxytocin, essential to the progress of labour and birth.

No bed
There might have been some rolls of hay to lean on or a manger or two to hang off, but there certainly wasn’t a bed, and it’s likely that Mary birthed, like many women of that time, with the help of brightly painted birthing bricks, brought by the midwives and used to squat or kneel on. This ‘active birth’ – with the woman shifting position several times in response to her body’s needs – is rarely seen in hospital deliveries whether on TV or not, though the bed slap bang in the centre of these delivery rooms gives women a strong message that this is the ‘way it’s done’. In reality, restricting movement makes for longer labours and putting women on their back narrows the pelvis making it harder for baby to get out.

No clock
Lucky old Mary would never have been told “Time’s up, you’ve failed to progress”, but for modern women, time features heavily in their childbirth stories. “You’ve been pregnant too long, we need to induce you”, “You’re not dilating fast enough, we’re going to speed you up”, “You’ve been pushing for over two hours, time for the forceps.” No wonder there was such a great sense of peace in that stable: what a relief it would have been to give birth without the sound of ticking in your ears.

Microbiome
In the modern age, we’ve become obsessed with cleanliness, perhaps to the point of threatening our well-being. Scientists are now beginning to study the Microbiome, the colony of bacteria that lives on us and in us, and the vital role they play in our health. And guess when the microbiome begins? At birth. Scientists have found noticeable differences in the microbiome of babies born at home versus those born in hospital, and the difference is also clearly marked between vaginally and caesarean delivered babies. Being born vaginally, and in a home-from-home environment like a stable, could have made for a very healthy start in life.

Animal Magic
The presence of animals in the birth room might seem odd, but perhaps it could have been strangely comforting. Added to this, it’s surprisingly healthy: scientists also tell us that living in close proximity to animals may be good for our immune system and overall health. In fact, the scientist who led the recent study ‘The Home Microbiome Project’ went straight out and got a dog, having discovered that a key to good health was having a rich, diverse microbiome, and that this could be instantly improved by ‘opening windows, adding plants and getting a pet.’ Or, in Mary’s case, a stable, a couple of palm trees and a sheep or two.

One to one midwife
We don’t know for sure who attended Mary in labour, but almost certainly, a woman from Bethlehem would have been sought, and she would have brought herbs, birth bricks and a wealth of experience and reassurance. She would have stayed with Mary from start to finish – a luxury modern women can only usually rely on if they hire anIndependent Midwife or are citizens of Aotearoa- New Zealand The ‘one woman one midwife’ model of care that Mary and New Zealand women enjoy has been shown to improve both quality and safety at no extra cost, but it is yet to be implemented across the board in the UK, despite NICE recommendations.

A Doula or not??
Forget the three wise men, it’s likely that Mary’s midwife had a helper or two and that the stable was filled with the birthing wisdom of women, who would have held her hand, looked into her eyes, and told her, “Yes you can” anytime she said, “No I can’t.”

A ‘Hands off’ approach

For biblical women like Mary, the only hands on her in labour were probably simply those of reassurance, but not many 21st century women can make this claim. Even if they are one of the minority who give birth without caesarean, or instrumental delivery, they probably still have plenty of poking around, from the obligatory ‘sweeps’ to get labour started, to regular exams in labour to make sure they are not ‘failing to progress’. Whilst such exams may sometimes be helpful or necessary, often they do nothing but disturb the mammalian brain and undermine a woman’s confidence in her body.

No crib for a bed
In spite of the typical Nativity pictures, Mary and her newborn probably didn’t bother much with the manger but instead enjoyed all the benefits of immediate skin-to-skin once the birth was over. This instinctive response was over-ridden by the heavy-handed approach of the mid-twentieth century, when babies were whisked off to be washed and placed in the nursery. Now initiatives like Baby Friendly from UNICEF encourage mothers to reconsider the many benefits of skin-to-skin contact; from calm babies with more stable heart rates, to improved rates of breastfeeding, to better bonding, to a more diverse microbiome. And where modern women can often feel conflicted by confusing co-sleeping advice, Madonna and child presumably bedded down in a loving snuggle with no such worries.

We like to think we’ve come a long way since biblical times, and of course it’s true that birth is a lot safer now: in some circumstances, medical help is a life-saver. But it seems like in our rush to embrace medical technology, there are some things we’ve forgotten. We’ve built labour wards that might have every modern convenience but are missing some of the basic essentials. Perhaps in 2014, as well as encouraging more home births, policy makers might, like the Wise Men of old, bring some new gifts to labour ward: darkness, privacy, freedom of movement, support from women we know, and trust in the process of birth.

“Microbirth” examines evidence which links modern delivery practices with the reduction and loss of some critical biological processes making our children more susceptible to non-infectious diseases through-out their lives. For example recent studies have shown that babies born by Caesarean have an increased risk of developing asthma, type 1 diabetes, obesity and other diseases linked to the immune system;up-to 30% higher than children born vaginally. Other research also shows that the process of vaginal birth which involves a cocktail of hormones for mother and baby in labour, sets the best beginnings for our immune system and subsequent health. International experts in the film also forecast that the current escalation of these non-communicable diseases is a potential world health catastrophe which could bankrupt many nations!

Auckland hospitals Caesarean Section rates in 2013 are; National Women’s 30%, North Shore 30%, Waitakere 24.6%, Middlemore 22% !

Further explanation of the Microbiome and its implications on pregnancy is here; Midwifethinking

Each baby and its placenta, cord, amniotic fluid and membranes develop simultaneously following the union of the ovum (egg) and sperm. Placental function begins from implantation until the baby has moved to life outside the womb, if we allow it to complete its work.

In the womb, the placenta does the work of a heart, lungs, kidneys, endocrine and digestive system for each baby as it grows; pumping blood through baby and placenta; taking oxygen and other nutrients from the mother’s blood as well as protecting the baby from many toxic substances and excreting most growth waste by-products (some is left in the baby’s bowel; this is meconium). Placental hormones maintain the pregnancy and promote fetal development as well as initiate and maintain labour, and together with placental antibodies these hormones are vital to optimal health for the baby’s life.

Placental delivery or birth?

Delivery of the placenta or ‘Active Management of the Third Stage of Labour’ (from delivery of the baby to delivery of the placenta and membranes) involves interrupting the natural hormonal flow and pacing of this event by injecting an artificial stimulant, early clamping of the cord then positioning and prodding  the mother so another person can try to safely pull the placenta out of her. A review of recent developments of placental delivery practices shows that most if not all, lack consistency, evidence or consideration of natural methods though there is recognition of some harmful consequences of these procedures. This is particularly so in regard to clamping of the cord as explained by Midwife Rachel Read and myself in a previous blog.

On-line articles by Midwife Rachel Read and Dr Sarah Buckley explain the differences between how to support physiological birth of the placenta and fostering ‘Active Management’ or placental delivery and some of the harms and benefits of both approaches. As suggested by Rachel’s list of the factors which aid physiological placental birth, natural placental birth firstly requires that healthy women chose to birth in a supportive environment (usually not a hospital) and be attended by people who protect and promote effective flow of the labour hormones (usually an holistic homebirth midwife).

However a placenta is delivered or born, all placentae are examined for completeness and features which may impact on the health of mother and, or baby. This event should also be shared with the family as well as documented in the woman’s notes.

True ‘Afterbirth’ care choices.

Once the cord, placenta and membranes are out of the mother’s body there are other choices about their treatment other than cutting, clamping and disposal such as;

• The cord maybe tied off with a soft, bought (eg thick dental floss or a shoe-lace) or hand-made tie of either flax-string (‘muka’) or plaited threads, rather than clamped by a rigid peg.
• The cord may be burnt or ‘candled‘ to separate it from baby rather than tying or cutting it.
• ‘Lotus birth’ practices support the natural separation of placenta and cord from the baby, which can take from 3 to 5 days and encourages gentle, low levels of baby handling which can be advantage .
• Creating a placenta print is a way of remembering the unique features of your baby’s placenta as well as honouring it.
• Planting a tree over a buried placenta is enhanced by the use of a traditional and, or ecological container such as an Ipu Whenua basket.
• Placenta encapsulation or placentaphagy is one form of placenta ‘medication’ to aid recovery from lost blood and, or hormones that can impact some women even following a ‘good’ birth. Professional encapsulation costs about $NZ 250 -280 and takes 3 days. Alternatively small placenta pieces can be individually wrapped and frozen, or dried by slow cooking @ 80 degree in an oven over a week. Either way the fragments are swallowed like a tablet regularly or when needed over the first week after birth.
•  When frozen for storage before burial or other usage, a placenta needs to be clearly labelled!

Whenua

At the beginning of your world, I was part of you.
Made of the same luminous fabric, flesh of your flesh, of our father and mother’s being.
As we grew, we were separated but united.
I fed you, breathed for you, became a pathway for the flushing currents of our mother’s blood.
As you slept, I was your cradle and your guard; when you awoke I was your companion.
Together for that last day I leashed you the very limits of our linking line before
releasing you to the touch of others – lovers, yes – but surely none will hold
you as nearly, as sweetly or as softly as I did.
As our connection was severed you wept for me once, then were gone.
Carry me deep in your heart as you bury me in the soil of our home,
for I am the earth of your making.

Kate Alice 2002

The Maori name for placenta is Whenua, which also means land or environment; such a name is reflective of the placenta’s importance to Maori and in reality to all of us.

There are only two languages: Love and Fear

There are only two activities: Love and Fear

There are only two  motives, two procedures,

Two frameworks, two results : Love and Fear,

Love and Fear.

Michael Leunig