Honesty in Birth Preparation

Aug19

Some time ago I came to the disheartening conclusion that what many independent birth educators like myself teach women in birth classes isn’t actually what they can expect, it is what they deserve. And, in our birth culture there can be a dramatic difference between the two. I then wrote an article exploring what many women can expect from a traditional hospital-based “natural” birth—it was published in Pathways magazine and has also made the rounds multiple times as a blog post. So, what then do women deserve? In my mind, they deserve: humane care; respectful, individualized treatment; freedom of movement and choice in a woman-honoring environment; informed consent; the Six Healthy Birth Practices; and the recognition that birth is a significant rite of passage and transformative life event. With this conviction, I therefore refuse to start teaching only what can be expected, because women deserve so very much more than that—but, how to professionally handle the dichotomy in class?

Published in the 80’s, the book Childbirth with Insight by Elizabeth Noble has some thoughts on the subject offer the birth educators of today. In the section addressing the issue of being honest with childbirth education clients about common obstetric practices, she says:

“…instructors in the community cannot afford to discuss obstetric practices in ways that will aggravate local hospitals and obstetricians if they wish to fill their classes. One childbirth educator comments, ‘Imagine if we told couples how it really was…perhaps we’d lose fewer teachers from our group.’ No wonder many of these dedicated and enthusiastic teachers suffer ‘childbirth preparation burnout.’ They are caught in a triple bind. If they describe accurately how birth is managed in some hospitals, couples would become very fearful. If expectant parents anticipate a warm and flexible birth environment and find that such is not the case in the hospital they use, their disappointment is inevitable and bitter. If the instructors advocate childbirth without drugs or anesthesia and these are needed, parents may harbor feelings of guilt and failure.”

The author concludes this segment of the discussion with a very potent and powerful message to birth educators:

“Each instructor must teach what she knows in her bones to be true. A dynamic teacher is constantly changing, becoming more self-aware. At the same time, couples must be warned that almost all hospitals and doctors have expectations based on the mechanical model of birth.” [emphasis mine]

This is such a difficult line to walk—to encourage confidence, trust, and joy in childbearing, while being straightforward about the challenges couples may face when seeking a natural birth experience in a hospital. I always encourage couples to “assume good intent” from hospital staff—they offer medication because they feel like they are helping and also simply because it is the primary “tool” in their medical-model oriented helping toolbox. I also remind them that routines are powerful and if the majority of births occurring at a specific hospital are induced, medicated, heavily intervened with, etc. it can be difficult to buck the trend. Again, not out of some sketchy motive from hospital staff, but simply because of routine or “this is what we always do” or “this is what mothers want from us.”

The very firey, bold, honest, and passionate 1990’s manifesto on VBAC, Open Season even more bluntly addresses the issue of transparency in maternity care and also the effectiveness of childbirth education in this quote:

“If childbirth classes really ‘worked,’ more women would be having babies without interference. More women would be recognizing the complete naturalness of birth and would remain at home, delivering their infants with feelings of confidence and trust. More and more, midwives would be demanded. The names of those hospitals and doctors who treated women and babies with anything less than absolute respect would be public knowledge, and childbirth classes would be the first place these names would be discussed. ‘You’re seeing What’s-His-Face? He’s a pig! In my opinion, of course,’ I tell people who come to my classes. I then proceed to give them the names of people who have used Pig-face. They can always ask Dr. P. for the names of people who have used him and been satisfied with their births, for balance.”

While I’m not personally to the point of taking the “Dr. Pig-face” approach from Open Season, I’ve decided that honesty is the best policy and I’ve started to be very upfront about my challenge with the couples in my classes. Lately, I say, “here’s where I’m wrestling with something. I’m teaching you what you deserve, but it isn’t necessarily what you can expect…” and we proceed to explore choices, talk about communication skills, talk about evidence-based care, making sure the care provider’s words and actions thus far are matching, etc. However, my basic dilemma remains—I am not changing a broken system by teaching individual couples how to navigate it more satisfactorily, I’m actually supporting the broken system (right?!). While one-on-one change efforts have value and are personally rewarding, what I know in my bones to be true is that what we actually need is widespread maternity care reform and systemic change on a global level…

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(I originally posted some content from this post on the ICEA blog.)

Childbirth Educator as Midwife…

Aug14

“Expectant mothers need to be mothered; their hearts need to be infused with love, confidence, and determination. I now see myself as ‘midwife’ to the gestation and birth of women as mothers.”

–Pam England

This is a beautiful quote that really speaks to how I wish to work with women and what I would like to accomplish.

As I’ve noted before, I have a big binder of back issues of the International Journal of Childbirth Education and they are a real treasure. Here are several quotes that relate to the sentiment above:

From the Sept. 1999 issue in an article called The Challenge of Change: Making Mother-Friendly Care a Reality in Childbirth Education by Mayri Sagady comes a discussion of educator as “banker” or “midwife”:

[the concept of]..traditional education as ‘banking.’ This is where the role of the teacher is to ‘make deposits of information’ into the student’s mind. The student’s job is simply to ‘store the deposits’…the teacher as midwife [is explained as] ‘Midwife-teachers are the opposite of banker teachers. While the bankers deposit knowledge in the learner’s head, the midwives draw it out. They assist the students in giving birth to their own ideas, in making their own tacit knowledge explicit and elaborating it’…Within the field of childbirth education today, there are surely both ‘bankers’ and ‘midwife-teachers’

Then in the December 1999 issue in an article by Celeste Phillips called Family-Centered Maternity Care: Past, Present, & Future, she offers three challenges for 21st century birthing educators:

+”Help men and women understand that birth itself has the potential to change lives for the better.”

+”Give women a sense of fulfillment and tremendous accomplishment.”

+”Give new parents a strong connection to the very essence of life.”

These are formidable—and exciting—tasks! I think it is important to examine our own birth education programs to see how well we are meeting these challenges and also to strive to serve our clients as midwife-teachers rather than as of bankers of information.

And circling back around to my opening quote, I am reminded of another good one, this one from Midwifery Today’s founder/editor, Jan Tritten:

“You will have ideas, options and paths to ponder, but you will also have a sense of possible directions to take as you consider midwifery, childbirth education, or being a doula or an activist. Your path may be circular or straight, but meanwhile you can serve motherbaby while on the path, with a destination clearly in mind.” She also says, “I use the word midwife to refer to all birth practitioners. Whether you are a mother, doula, educator, or understanding doctor or nurse you are doing midwifery when you care for motherbaby.” (emphasis mine)

Childbirth Education Curriculum Preparation Resources

Aug10

Recently, I received a question from a new childbirth educator seeking resources for developing her class curriculum. I emailed her back with a couple of ideas and thought I would also share them here. Here are several of the most useful tools I’ve discovered for birth class curriculum development:

Prepared Childbirth, The Family Way: Educator’s Guide (from www.thefamilyway.com)
The teaching manuals sold (very affordably) by ICEA are EXTREMELY useful: Family-Centered Education: The Process of Teaching Birth is one of my favorites as is Teaching Pregnancy, Birth and Parenting. If you can get the ICEA Educator’s Guide, it is quite useful too (they used to sell it for around $7, but I don’t see it on their site right now).
Empowering Women: Teaching Active Birth, by Andrea Robertson is a class resource for developing birth classes—can be hard to find lately though.
I love The Pink Kit for all kinds of strategies and information about the pelvis and working with pelvic mobility.
Transition to Parenthood has a full curriculum outline available online as well as several great handouts and activities.

The ICEA resources have been my overall favorite, though I’ve added things from all kinds of other sources, as no single resource everything I want to share in a class-—I add information from all kinds of books, videos, reading, journal articles, etc. Every class I teach is a little bit different because I add and subtract things all the time! I only have one page outline for each week of class and it is PLENTY. I do not use power points or anything like that. Just me, lots of hands-on activities, a few visual aids, and the rapport established with my clients.

Good luck with your journey and enjoy making these classes your own!

Opening for Birth

Jul24

Some time ago, I bought several large binders of back issues of The International Journal of Childbirth Education (ICEA‘s publication). The December 2001 edition of the IJCE contains an article titled “The Pelvis Revisited” by Elizabeth Noble. An interesting article overall, I particularly enjoyed the language of the section titled Opening for Birth:

“Birth is what women do. Women are privileged to stand in such power! Birth stretches a woman’s limits in every sense. To allow such stretching of one’s limits is the challenge of pregnancy, birth, and parenting. The challenge is to be fully present and to allow the process because of inner trust. How can women find their power, claim it, and stand firm in it throughout? The vertical position comes again into prominence. Women must ‘stand up’ for what they want and ‘on their own two feet’ by refusing to take their birth ‘lying down’! Being upright is essential for pelvic power–psychological strength, pelvic mobility, gravity’s assistance, pelvic pump efficiency, and the hygienic downflow of bodily fluids.”

In the September 1999 issue, the article “Belly-Dancing Through Pregnancy: A Way to Give Birth and Not Be Delivered” by Gaby Mardshana Oeftering caught my eye. In it, she also addresses the needs to build inner trust and to open to birth through physical movement and an active approach to birthing:

“Women expecting their second or third child don’t necessarily need this [traditional prenatal classes]. They are looking for a way to relax, find their inner selves, and get better acquainted with their bodies, their babies, and the process of birthing. When allowed to move during childbirth, many women instinctively start moving their pelvis in hip circles which are typical of belly-dance…All soft and gentle belly-dance movements are beneficial to pregnant women; for example, hip circles, the various hip-eights, and hip rocking. The rule is: all horizontal movements relax the uterus; vertical movements excite it. Physically speaking, all these movements strengthen and mobilize the pelvis and the legs and train the pelvic floor. They also activate deep abdominal breathing…the hip movements demand a lot of attentiveness and body awareness. On a mental level, this leads to better consciousness of tension and relaxation—a body feeling that is needed during birthing.”

Recently, I feel myself intrigued by the possibilities of working with these women—those who are on their second or third pregnancies and who are seeking to “go beyond” traditional birth class information (that often assumes first baby status). I know that I, personally, have wanted new, fresh, inspirational birth information during each of my pregnancies—labor and birth 101, stages of fetal development, or even labor support and comfort measures isn’t “enough” for me anymore (and wasn’t after my first baby). The desire to honor the pregnancy experience, prepare for the birth experience, and to work with psychological and emotional elements of childbearing are still very much present though! I envision doing a series of “pregnancy retreat” type of things or other types of workshops that “go beyond” and help second, third, or fourth time mothers to spend some dedicated,special attention to each pregnancy and birth experience in a personally enriching and rewarding way 🙂

Practical Ways to Enhance Knowledge for Birth

Jun24

Related to my previous posts about information vs. knowledge, I want to share a couple of ideas from an article I wrote some time ago for the International Journal of Childbirth Education. Obviously, I don’t have all the answers, but these are some of my ideas/tips about transferring information into knowledge that will be meaningful to parents when their birthing time comes:

Use “The Ice Cube Minute” exercise from Family-Centered Education: The Process of Teaching Birth. In this exercise, couples hold an ice cube in one hand for one minute and see what coping measures spontaneously arise for them. I do this exercise fairly early in my class series, before we’ve done a lot of formal talking about coping measures. It is very empowering for couples to discover what tools and resources come from within as they try the ice cube minute.
To illustrate the potency of the mind-body contraction, practice two pretend contractions while holding ice. One contraction has an accompanying “stressful” paragraph read with it (“your body fills with tension…it hurts! Oh no!”) and the second contraction has a soothing paragraph read with it (“you greet the wave….it is YOUR power….”). This illustrates the fear-tension-pain cycle viscerally.
Use a five minutes series of birthing room yoga poses to begin the class—birth happens in our bodies, not our heads. Practicing the poses opens space to simultaneously discuss and practice: squatting, pelvic rocks, optimal fetal positioning ideas, healthy sitting, pelvic floor exercises, leg cramp prevention, back pain alleviation, and more.
Role playing cards-—talk through various scenarios. I’ve found that couples are more receptive to talking through the cards than actually getting into a role and playing it through. The activity that seems to work best for actual role play is the labor simulation series available on the Transition to Parenthood site.
Values clarification exercise—participants cut out values from a list and arrange them in a grid to help them figure out if they are in alignment with each other and with their caregivers.
Leg stretch exercise to explore the use of vocalizations and other coping mechanisms during labor.
Ask plenty of open ended questions that stimulate discussion and ideas, “what have you heard about XYZ?” or “what is your experience with…?”
Use birth art processes to “switch” parents from linear, logical, left-brain thinking into the right-brain mode they will also enter in “laborland.”
Media portrayals of birth—show two contrasting clips, such as a birth from a popular TV show (I often show Rachel’s birth from the show Friends) paired with an empowering birth from a film like Birth as We Know It and then have students discuss the two. Sometimes this more clearly brings into focus the influence of our culture on birth practices than a simple discussion does. Since I originally wrote this, the film Laboring Under an Illusion was released which does exactly this—contrast media portrayals of birth with how birth can be. It is a great resource for birth classes.

In classes, I also incorporate the idea of mother-baby symbiosis through:

The use of affirmations—“my baby and my body work in harmony to make birthing easier.”
A discussion of cardinal movements with an emphasis on how the baby moves to help itself navigate the pelvis (thus, helping you have a smoother birth).
Visualization exercises that encourage “seeing” and connecting with the baby while in the womb.
“Belly Mapping” to get a sense of the baby as a person positioned in the uterus. Talking about what baby is like in the womb—when does it kick more, when is it quiet, does it like music, poke you back with you touch it, etc.
Impressing upon participants that it is not selfish to want both a good birth and a healthy baby (I actively challenge statements about, “well, in the end, all that matters is that the baby is healthy”). Laboring women have a basic right to humane care, which supports both a happy, satisfied mother and a healthy baby. I use examples during class to show how these are intertwined—for example, a stressed, unhappy, unsupported, tense mother may have a baby with heart decels and accompanying distress.

I try to build a sense of confidence through:

Opening each class with a brief series of “birthing room yoga” poses to help couples become comfortable using their bodies and moving from “head space” into “body space.” Birth is a physical process and I am convinced that it is vital to include physical movement during every class to bring that message home. Additionally, the poses I teach can all be used while in labor (thus, building confidence in coping “tools” for labor).
Emphasizing active birth—freedom of movement through labor helps baby rotate and descend and helps mother feel more comfortable.
Encouraging active birth on all levels: First, the physical level–being active during the actual physical process of birth. Second, the mental level–mentally engaged with labor. Third, a cultural level—a perspective that sees women as active birthgivers, not victims of birth. Birth is something women do, as opposed to something that “gets” them.
Giving couples plenty of time for hands on practice of labor support and coping measures. I have a personal motto for classes of, “talk less, learn more.” Practicing support tools in class helps them develop a sense of confidence in having a well-stocked toolbox for labor, instead of being a victim of pain.

Recommendation: Luna Protein Bar

Jun23

So, I’m a big one for recommending books, but not usually so big on recommending other products. I am also very careful about what samples/product information I give out during my classes. There are ethical issues with distributing just any old sample that someone sends you because you are a childbirth educator. However, I do have a snack recommendation for today! I regularly get samples of mini Luna bars to give away during my classes. I like putting them into my client packets—they make them look exciting and “goody”-ish :)—and, I also like putting a little pile of them on the table for people to snack on during class. (I also bring them to my various mother’s group meetings for the same purpose.) Some time ago, Luna Bar sent me a single full-size sample of their new Luna Protein bar. It was really quite good and since then I have bought them at the store when I’m grocery shopping and start casting my eye towards the candy bar aisle. The Luna Protein bar actually has a candy-bar-ish appeal (kind of “nougat” in the center and chocolate on the outside), but is made from mostly organic ingredients and things with actual nutritional value and is good for you as well as pretty tasty. So, I was VERY excited today to see UPS arrive with my regular shipment of mini Luna Bars AND, surprise!, a big box of full-size Luna Protein bars for my classes! They included three different varieties (cookie dough, chocolate peanut butter, and chocolate cherry). <happy dance> 🙂

Pain Pie Exercise for Birth Classes

Jun9

I address the issue of pain in several ways during my classes. I have struggled with doing this—by mentioning pain do I plant the seed that their births will be painful? etc. I’ve eventually come to a place where I feel like it is important to mention pain directly and to look at it head-on. Many people have the perception that birth is THE most painful thing ever and essentially the most painful thing anyone could ever imagine. So, I feel like by not talking about pain in class, I would be ignoring the elephant in the room of THE (cultural) pinnacle of pain. While I have no doubt that birth can be very painful for some women, I deeply feel that our current birth culture and manner of treating birthing women makes birth painful for more of them.

A very useful tool in exploring sources of pain is the “Pain Pie” idea from Teaching Pregnancy & Birth: A Childbirth Educator’s Perspective by Marcy White (published by ICEA). With this tool, you create a red circle with the word pain on it and a separate set of white wedges (pie pieces) each containing a supportive element, such as “movement” or “relaxation techniques.” Each piece of pie covers up a portion of the red “pain”—as elements of the pie are removed, the pain piece gets bigger and bigger (an alternative presentation is to add pieces, so that the pain gets smaller).

I mention that too often women in our society are left feeling as if they “couldn’t do it” or that their bodies failed them, but in reality their coping pieces of the pie were stripped away from them (sometimes forcibly). I also talk about how sources of distress to the mother during labor: lack of emotional support, disrespect, ignoring of needs, repeatedly offering medications when none are desired, and restriction of movement, often have little to nothing to do with pain, but instead to what is happening around her (environment and caregivers).

Book Review: Painless Childbirth: An Empowering Journey Through Pregnancy and Birth

Jun3

Book Review: Painless Childbirth: An Empowering Journey Through Pregnancy and Birth

By Giuditta Tornetta
Cumberland House, 2008
ISBN 978-1-58182-640-1
320 pages, softcover, $16.95

http://joyinbirthing.com/

Reviewed by Molly Remer, MSW, CCCE

Written by a mother of two who is also a doula, childbirth educator, hypnotherapist, Painless Childbirth takes the pregnant mother on a physical, mental, and spiritual journey from conception through postpartum. The text is interspersed with personal stories from the author’s own pregnancies and births as well as those of her doula clients.

A lot of people are initially skeptical of the phrase “painless childbirth” and I really loved the author’s description of what painless childbirth means: “When I say painless, please understand, I don’t mean you will not feel anything. What you will feel is a lot of pressure; you will feel the might of creation move through you. Pain, however, is associated with something gone wrong. Childbirth is a lot of hard work, and the sensations that accompany it are very strong, but there is nothing wrong with labor.” The book has no rigid concept of what “painless” means and no suggestion that mothers who do not experience birth as painless have “failed.” Painless Childbirth is written in a gently nurturing tone throughout (you can “hear” the author’s doula skills coming through), but is also very assertive that painless childbirth is very reasonable, doable, and is, indeed, the birthing mother’s right.

The book contains a lot of ideas and concepts that are of use to doulas and childbirth educators. I particularly liked Tornetta’s characterization of the three phases of first stage labor according to the primary means of coping with each phase—distraction, concentration, and surrender.

After my own experiences with pregnancy loss, I have become more aware of the treatment of the subject in birth books. Painless Childbirth directly addresses childbearing losses in a short, but compassionately written segment about healing past grief. The book also has content about exploring and overcoming fears.

The book is holistic in its approach, addressing body, mind, and spirit. It contains a lot of spiritual content of a “new age” flavor (for example, lots of references to the law of attraction and the book is organized by month according to fetal development as well as associated body chakra). While I definitely agree that birth is a spiritual event, my practical, down-to-earth side stumbled a bit over some of the concepts and phrasing, and the esoteric content may not appeal to all audiences. That said, Painless Childbirth presents a positive, loving, welcoming approach to giving birth that is both refreshing and interesting.

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Disclosure: I received a complimentary copy of this book for review purposes.

WomanSpace

Jun2

Yesterday, a friend/colleague and I toured a possible studio space to rent in Rolla. We do not have a particularly clear idea of what we’d like to do exactly, but we have both long felt the desire to create a “women’s resource center” as well as to have a dedicated “birth studio” for our birthwork (she is a doula and I’m a birth educator and soon to be prenatal yoga teacher). The space felt perfect and was in our exact price range. I left feeling tremendously excited and inspired about the possibilities. Later that evening, the doubts, realities, and fears started to crowd in—I do not want to live a fear-based life, but I also want to be “practical” (which can be a handicap as well as an asset). I have too much to do already, etc., etc. In February, after my miscarriages, I took a personal renewal retreat in which I kept my computer off for 5 days and spent the time nurturing myself and doing those many things I always say I “really want to do.” During that time, I spontaneously wrote a description in my notebook of the women’s center I envision. So, this morning I opened up my notebook and re-read my “vision” there. I want to share it now and continue to explore the possibilities angle of the studio opportunity, rather than get bogged down in fears and self-doubts:

I visualize a center. A place where women can come together to learn, to talk, to develop, to grow. A safe place. A nurturing place. A supportive place. Hostess to LLL meetings, book clubs, birth circle, birth info nights, prenatal yoga classes, birth classes, birth art workshops, pregnancy retreats, journaling workshops, craft classes, crafty mamas meetings, a miscarriage support group, postpartum mamas support group, birth counseling/consultation sessions, dancing for birth, prenatal bellydance, drop-in support chats, blessingways, red tent events, meet the doulas night, Mother’s Guide to Self-Renewal groups, women’s spirituality circles, playgroups, baby massage classes, baby/tot yoga, girls’ coming of age classes, an ICAN chapter, Friends of Missouri Midwives meetings. A gathering place. A woman’s place.

It will have a large, open meeting room, access to a bathroom and another, smaller room that could be an office, consult room, or playroom. We will have counter space to plug in some minimal cooking implements (like a microwave). There will be comfy couches, chairs, toys, a lending library of books and films as well as perhaps toys/games/puzzles. There will be big pillows on the floor and beautiful art all over the walls. Other women wishing to have groups/classes for women, could also use the space for their groups/events.

Think we can do it? (And, if so, what can I not do to make space in my life for it? 😉 )

In a way, my vision is that this will be that classic “room of one’s one” that every woman needs access to. WomanSpace.

Information ≠ Knowledge

May24

Last week I attended a webinar about the ethics of childbirth. The presenter, sociologist Raymond De Vries, noted that choice is central to each of the ethical questions surrounding birth and then made the point that the problem with choice is that information does not equal knowledge. (He also mentioned the “ritual” of informed consent.) In the context of the webinar, the point was being made about ethical issues of prenatal testing, birth planning, and asking women to make decisions while in labor, but I think it has broader implications for our work as childbirth educators as well. We spend a lot of time informing and educating women about their choices surrounding birth and are often then surprised that this apparent information does not translate into experience once in the birth room. Obviously, this is partially because the birth room is a context impacted by a large number of social, cultural, psychological, and environmental factors, but I believe it is also because with all of our information we still haven’t managed to help parents develop knowledge and the two are not the same. Parents are often not able to recall or to mobilize information resources while actually embroiled in the birth experience. They need an inner knowing and inner resources to draw on for coping.

While I have known this for a long time, I still find it difficult to translate my conviction into practice. How do people develop knowledge about an experience that is ultimately unknowable until they are in it?

I do think that within the field of childbirth education, Birthing from Within is the method that most attempts to address this issue and I really value these two quotes from Pam England:

“A knowledgeable childbirth teacher can inform mothers about birth, physiology, hospital policies and technology. But that kind of information doesn’t touch what a mother actually experiences IN labor, or what she needs to know as a mother (not a patient) in this rite of passage.”

“While all of your (birth) planning may spin a cocoon of security, in actuality, the course of your labor is unknowable…your critical task is to prepare for a birth that has NO script.”

Personally, though, even with the practices and ideas offered by wonderful resources like Birthing from Within, I find I am still working on the actual execution of the how in my classes of translating information into knowledge…

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Edited to add…I’m working on resolving this discrepancy through my new plan to offer birth workshops as part of a birth network, rather than as an independent educator.