By Sian Hannagan

Our Editorial.
Jun 2014

Birth in New Zealand has come a long way due to the efforts of the women and midwives before us. Since the Nurses Amendment Act was instated in 1990, women got a real choice in their place of birth. Annette King in her address at the 100th anniversary of Midwifery in NZ in 2004, said “Although the amendment to the Nurses Act was minor, the consequences for midwifery were significant. The most important outcome of that piece of legislation for midwifery was that it permitted midwives to operate as fully independent providers of pregnancy and childbirth services without reference to or supervision by medical practitioners. This amendment signalled a huge change in the birth culture of New Zealand. Prior to this change, birth looked very different. I remember talking to my mother in law about her births. When she was birthing my husband, she was told by the nurses to “hold on” and “keep her legs crossed” so that the Doctor had time to arrive and deliver her baby. He turned up, just in the nick of time, and smoked a cigarette while he watched her birth her baby and left shortly thereafter. He got paid a tidy sum for his attentive care. With the nurse’s amendment act, medical practitioners lost their monopoly on funding, causing the power balance to shift, the result being more choice for women.

However, as we enter the 21st century, while the same law is in place, we still have to overcome obstacles when it comes to our view of birth. A culture of fear has permeated our birthing milieu. From alarmist reporting to emergency birth shows such as ‘One Born Every Minute’ and the activism of certain social interest groups there has been a shift in the language and the way we frame birth. Women are often defined by what they are ‘allowed’ and ‘not allowed’ to do during birth. These social signals, directly and indirectly, erode our birth choices, if not by law, by social pressure. Women choosing to birth at home are often subjected to professional and peer pressure, sometimes even pressure from their spouse to birth in a hospital environment.

New Zealand is often held up to other countries as an example of good midwifery based birth-care, and we do have a great system. But if we aren’t aware of it and if we don’t utilise it, then is this enough alone? Given that many health and social services have changed significantly since the nursing amendment act. It is sometimes a surprise that our birth care has remained mostly unchanged. But can we rely on this to continue?

The global culture of birth has become the forefront of feminist discussion. More and more we see women being treated as secondary to the infant when it comes to pregnancy and birth, more often than not, a mothers needs and an infants needs are pitted against one another as if they are mutually exclusive. This cultural and medical myth allows women to be marginalised in birth. The truth is that in birth, the mother and baby do not have greatly differing needs. By serving the mother, you serve the baby. Birth violence, for many women, has become the norm, so much so that women who have had traumatic experiences don’t speak out, or feel unable to speak out. It seems that informed consent matters less for women giving birth than people receiving other hospital care. Many women experience coercion, and if they speak to this experience, they are silenced with phrases such as “Well, as long as baby is okay then there is no problem” and “you should be happy you’re alive and your baby is alive” sometimes these statements echo the statements made against feminists when they question patriarchy. As we might hear “not all men” we hear “not all birth professionals”, which while being ultimately true, does not undo the trauma experienced by women at the hands of some birth professionals, it is however an effective silencer. It ensures that women and their experiences do not get heard.

Landmark law suits such as the Ternovsky vsHungarycase, are framing birth as a human rights issue. Is this what we need to do to ensure we continue to be able to choose our place of birth? Take a legal stance? Things have not reached that level in New Zealand, but in our close neighbours Australia and further overseas in America, this is often the only recourse for women being denied their basic human rights when it comes to birth.

More than ever, we need the voices of our birth luminaries to continue to speak for the birthing mother as too often her voice is talked over by a culture of fear. It is now that we feel the loss of Marsden Wagner, a perinatologist and perinatal epidemiologist who served as a Director of Maternal and Child Health for the California State Health Department and was also the Director of the University of Copenhagen-UCLA Health Research Centre, and Director of Women’s and Children’s Health for the World Health Organization. Wagner’s work supporting midwifery and birth rights was invaluable. He spoke of the movement against homebirth as a ‘global witch hunt’ and wrote a number of books that pulled apart our commercial birth model. He chaired three W.H.O consensus meetings, where the appropriate use of technology during birth was discussed. His mark on the birth world is indelible, and we are better for it. Another voice in birth that has recently left us is David Chamberlain, psychologist, author, and editor who has lectured on birth psychology in 20 countries. His work in exploring and resolving birth trauma experienced by the infant was landmark and paved the way for our understanding that experiences of birth affect not just the mother, but the baby too. These are two great voices in the world of birth rights that have now fallen silent. 

Closer to home we remember Joan Donley, author of ‘Save the Midwife’. Joan Donley was a key visionary when it came to birth and midwifery in New Zealand in the 80’s and 90’s. Her tireless work led in no small part to the system we have now. Previous to the nursing amendment act, Joan felt that the role of the midwife had been undermined and could vanish altogether if not protected, in 1985 she published Save the Midwife (New Women’s Press), which charted the history of the profession and placed midwifery in New Zealand within the political sphere.

Joan was also a founding member of the NZ Homebirth Association and in 1989 she played a key role in the establishment of the New Zealand College of Midwives. In the same year she was made an OBE in for her work in birth advocacy and midwifery. Her work placed New Zealand midwifery in a position to be a world leading system. These successes were a result of tireless work and lobbying. As we reflect on these past challenges, we also need to look forwards. With the rights of women being challenged globally, it is not time to be complacent. Have vocal birth activists had their time? or do we need them now more than ever? In his interview with Home Birth Aotearoa Michel Odent noted that it was a paradox that Countries like New Zealand had a strong natural birth movement, but that Caesarean rates were on the rise, have we made the best use of your resources and energy to drive change? What is the future of Home Birth in New Zealand?

Sian Hannagan our Interim Editor

A letter on Joan Donley – by Margo Townsend

My first experience with Joan was at a tutorial at the Auckland Midwifery School in 1991.

She was a guest speaker. I remember she covered many topics, not the least being the importance of “getting out of the hospital setting and into the community” where she felt was where Midwifery Skills and Confidence could be gained. Remember I am talking 1991 most of my class were looking towards hospital setting placements, thinking that was where we would get the experience that we would need to become confident.

Joan challenged that notion and suggested that by working outside the hospital setting we would discover our strengths and also would more readily be in a good position to support women in their choices around birth.

She offered to take a student under her wing to experience the Home Birth scene. I was the very lucky student Midwife who got to go with Joan those were some of the best weeks of my life in midwifery.

Joan was fearless in the protection of normal birth and women centred care. She often said things that were quiet deliberately challenging of the system of the day. She called obstetricians “the boys” said with humour, not I feel in a disrespectful way, but rather in a frustrated way about some of the institution driven protocols that prevailed within the hospital setting.

She enabled me and many others, midwives and women alike, to see that there were options outside of hospital and indeed even inside the hospital setting. She subscribed to the notion that women, given the chance, and support could (and did) birth naturally. She empowered me to be a midwife who held women central to the pregnancy and birth journey.

She really made me think about being with and alongside women, at the same time she was mindful that I was a student and she made sure that I was exposed to as many experiences as possible: including making soup and scones and taking that meal along to a postnatal visit. My first home birth with Joan was in the suburbs of Auckland. a young Samoan mother having her third child graciously let me in to her birth experience.

The woman was surrounded by other women relatives and Joan took up her position in the corner of the room, watchful, calm and trusting the process of Birth. Joan did check the fetal heart with her Kauri “listening ear” and the woman let Joan know when the baby “danced”. I had come from a hospital setting where even ‘normal’ women were hooked up to the CTG for at least 20 minutes upon arrival in the delivery suite, so this was all new to me! And a bit unsettling, but Joan had talked this through with me before we arrived at the house and she had gone through her box of homeopathy remedies as well, should they be needed, that would be my job to pass the remedy to Joan. My other job was to sit quietly and not fidget!
The woman had her baby on the floor with Joan’s encouraging words. It was such a wonderful experience. Very removed from my own birth experiences or the hospital births I had witnessed GP’s being called in to deliver the baby etc. None of those here just encouraging words from family and Joan.

A PPH of about 600mls followed and was sorted by Joan rubbing up the fundus and me passing the correct homeopathy bottle to Joan, and the woman emptying her bladder I was mentally ringing three bells in my head and waiting for the IV insertion and the room filling up with health professionals. But no, just Joan, me and the women, of course if further intervention had been required Joan would have responded she was a safe practitioner.

That first experience taught me heaps. It taught me never to be anything but quietly vigilant and to have the confidence to intervene when necessary, to include the woman in all decisions, to acknowledge there are times when a cosy chat is inappropriate, that immediate response to an unfolding situation has to be dealt with in a timely way, but at the same time giving a running commentary to the woman as to what was happening and what we were doing about it ..Joan explained everything to the woman and did it whilst remaining calm and getting on with managing the PPH. We stayed for about 5 hours post birth. We had tea and cheese biscuits in between supporting the woman to breastfeed and then later to shower and go to bed for a rest, baby tucked in besides her. When we went back the following day for a check up of baby and mum we were greeted with excitement. There were presents for Joan and for me, a hand stitched pillow slip for me and a bed set of hand stitched sheets for Joan cos she was ‘the woman who helped the birthing mum’ I was the ‘woman who came with the helper’.

My experience with Joan taught me that when we enter a woman’s home, we are the guest and are women who know about the birth process but, we are not in control, we are not controlling the situation, we might even feel at times a little uncomfortable being outside of the hospital setting. Joan made a point of suggesting I reflect upon that and to remember that when women enter a hospital setting, they should be met by a midwife who knows and remembers what it’s like to feel out of one’s own comfort zone.

Joan’s way of ‘being’ with women within their own environment showed me that women are powerful and well able to birth without lots of protocol driven interventions. My ‘homework’ was to challenge, not just for the sake of it but to really stop and think is this really necessary, what purpose is there to this task, whose needs am I meeting by imposing Guidelines/protocols on this woman, is what I am about to do enhancing the woman’s experience or hindering the birth process? Why, for instance am I putting the CTG machine on this perfectly no risk healthy woman?

My time with Joan has stayed with me throughout my Midwifery days. The profession has a need for the Joan’s of this world. We need Midwives who dedicate their lives to the wellbeing of women and who are always prepared to ask the question Why are we doing this? Who are willing to challenge the system, even if it makes life a bit uncomfortable at times?

Joan Donley’s book, save the midwife

Joan on Normal Birth – Margo Townsend

I saw Joan work with doctors in the homebirth situation. She was always gracious, but focused on the woman, not the doctor, which seemed to work well with the doctors I saw her work with. I do not know to this day really if she secretly was cross at having the GP there, she never touched upon that subject, and I don’t believe I asked her.

I do believe that at Midwifery Tutorial time some of the tutors were a wee bit nervous about what Joan might say. We all had to be mindful that hospital placements were hard fought for and that any comments/observations made by Midwives contrary to hospital policy might jeopardize further placement opportunities, but Joan I believe was also mindful of that, but was not prepared to be compromised by not saying what she thought.

Mostly what I took away from Joan’s tutorial was to be sure of your facts, read heaps, speak up against practices that impacted on women in a negative way, trust women’s knowledge, accept women’s choices and maintain a safe nurturing environment for women and their families. She also thought women should birth at home if well and that far too many women were not informed of choice or supported in choice.

When I trained the climate was very much the doctor and obstetric teams ran the show and even though midwives were respected, we were not encouraged to question interventions and in fact got told off for not phoning doctors in a timely manner to attend births in hospital.

She believed change occurs when the public, in this case, women are fully informed and well supported by a vigorous passionate point of view around choice of how to birth and where to birth and Joan was a strong constant campaigner for change for women and a big advocate of Homebirth. She also thought that midwives should unite in a common cause and promote normal birth and be supportive of each other and not allow other professions to divide us.

A note to Margo – by Joan Donley

Get out of the hospital and find normal birth, when you find normal birth then you will know what to do with abnormal, you will recognise abnormal.

Keep your hands to yourself unless invited to do otherwise…a mother knows what to do. If you start off in the hospital system you will lose confidence…, how could you not…with so many things to do that fulfil someone else’s needs (certainly not the woman’s) how will you know how to trust the process trust the birthing women, honour and respect the birthing mother…you will be so busy kowtowing to the institution that she will be lost from your sight.

Obstetricians are good when you need them, but often, too often, you don’t need them it’s just that they fool you and themselves and the women that you can’t do without them…. but that’s boys for you. If you ever think you know everything there is to know about Midwifery…run for the hills…. you are no good to anyone when you think that. If you think you know everything about birth, then you have lost the excitement of midwifery. If you say you are going to turn up for an appointment, then you better make sure you do. Even if you are late. There is nothing worse than a no show midwife, how can a woman trust you if you don’t show up at her house? Sometimes you might have to take your shoes off so always good ideas to wear socks or have them in your bag. Cold feet are a distraction. Most women like my homemade soup and I like making my homemade soup for most women. Be brave and challenge the system. If we don’t challenge the system, we might as well pack up and do gardening. I want you to pick your battles, there will be plenty of them over the years, so you have to pace yourself. Be a friend to yourself. If you can’t be a friend to yourself then find someone who will be your friend and give it to you straight like a friend should. If you don’t question yourself, how will you know what to do next time round.

“Be brave and challenge the system. If we don’t challenge the system, we might as well pack up and do gardening. I want you to pick your battles, there will be plenty of them over the years, so you have to pace yourself.”

Good luck Margo,
Work hard.
Stay out of hospital.
From, Joan.

All letters and notes kindly supplied by Laura Madden, midwifery student.