Hannah Dahlen on Midwifery.

By Home Birth Aotearoa
Oct 2018

Hannah Dahlen is well known for her advocacy work in the maternity community, particularly around human rights for childbirth, and the promotion of normal birth. Her voice is one of the guiding lights, leading the way for some long overdue fundamental changes to the maternity system in Australia. It is a highlight for Home Birth Aotearoa to have secured an interview with her.

Having recently attended the ‘One voice’ NZCOM conference in Rotorua, I had the pleasure of seeing Hannah Dahlen talk in person. Her talking piece was a powerful commentary on where midwifery is now and where it came from. She highlighted some of the absolute strengths of midwifery led care and made a strong case for keeping our midwifery led maternity system alive – and thriving

It was an inspiring talk, which brought a lot of the audience to tears and at the end, a standing ovation. Having a one on one video interview with her was no less inspiring. She got to admire my laundry pile and I got to admire her absolute clarity on key birth issues, here and in Australia.

Photo by Holly Priddis

What brought you to birth work?

I was born in Yemen, and my mother was a midwife, and I grew up surrounded by women and birth. There was never really a point in my life where I thought I wasn’t going to be a midwife. I saw my first birth when I was 10, I begged my way in. I was a little bit disappointed because the woman sort of lay flat on the bed and it all seemed very sort of mundane.  I expected there would be cymbals, and angels singing, and ecstasy, but it was all very matter of fact and then she was bundled up and got back on her donkey and went back into the mountains again with her partner.

Then my next-door neighbour who was my best childhood friend, her sister in law was having a baby and I again begged my way into the birth, and I was there that night, when she gave birth.  I was just 5 days shy of turning 12 and I helped the local midwife catch the baby, and it was a little girl. They named her after me, so her name was Hannah. When Fatima who was giving birth saw that it was another girl, (they already had two) she said take it away. I remember feeling so outraged that her rejection was based on the sex of this child. It wasn’t really her fault though, because if she didn’t produce a son she would be divorced, and he would remarry another wife. There was just no acceptance from men that they determined the sex of their babies.

So, I took this baby across to the window and the minarets were calling, dawn was breaking over the middle east and I just remember thinking, this has got to be the best job in the world. Feeling absolute awe and absolute rage, and I think that really has formed the feminist midwife that I am today. It is the most amazing thing that you will ever be a part of, women and midwives are incredible. So undervalued, and this amazing job they do is so unrecognised and so unsupported. These two things have really been the foundation of my birth work and my birth advocacy.

Your advocacy work across the ditch is inspiring, many of the messages you share apply to birth in any country, but what would you consider to be the key differences between the Australian Maternity system and the New Zealand Maternity System?

I think I have a much better understanding of the NZ maternity system having been across to speak at the NZCOM conference this year and I also go to Christchurch every year and review the Bachelor of Midwifery Program at Ara Polytech. I am getting a much better idea of the differences and I would say NZ has the best system in the world. At least as far as for women it has the best system in the world. It has the most amazing continuity, it is publicly funded, it has incredible autonomy for midwives, it has a general acceptance of recognition and acceptance of the right for women to choose. On the surface I think it is absolutely the best system in the world and it is the gold standard.

However, I think it is a really poor system for midwives and I think the lack of reasonable pay, the lack of recognition, the lumping together a group of (professionals) because they are predominantly a female workforce, for a country that gave women the vote first in the world this is a really inexcusable situation to be in. You have had a prime minister who took a photo with a midwife when she gave birth and celebrated midwives, a minister for women who has had midwives and celebrated them. You have so many parliamentarians who know how important midwives are. That this has not been recognised and supported yet I think is a disgrace. I feel like it is at crisis point. But it feels like you just limp on and limp on. An explosion at some point is coming, then eventually they will do something but how sad that you have to drive a workforce into the ground, that you have all of these highly trained (and experienced) midwives that are leaving – or coming to Australia which advantages us but not you. -But the politicians don’t do something about it. It’s shameful. It is particularly shameful for a country that leads the world in strong women and defending women’s rights.

If you could take one thing from the NZ maternity system and apply it in Australia – what would it be?

Gosh, I would want more than one thing, but what really impressed me no end about the NZ system, is the cultural respect and recognition for the Māori people. It is not just tokenistic like I believe it is in Australia. We add it in, with an acknowledgement, but it is not embedded in our language, it’s not embedded in our greetings, it’s not embedded in our policy in the way we design our units and the care we give, whereas I do feel, and I am sure Māori people would feel there is a long way to go, but compared to Australia, wow, it is so impressive. Culturally so impressive, from my perspective.

The second thing, the key thing I would take from the midwifery system in NZ is the continuity of care. The autonomous, self-employed midwife wherever the woman wants to birth with that midwife is available publicly and funded. That I would love for Australia, but we would have to have the midwives paid well and recognised for their hard work just as NZ needs to have if this amazing system you have is going to survive.

Do you think there are any valuable elements to the Australian maternity system that we could utilise in NZ?

The one thing I think that NZ is getting much better at, but I’ve noticed this happening in countries where they’ve fought hard, and they’ve got a strong midwifery system. I’ve noticed they’re not as actively together around research, or political around research. They are very political but getting the evidence that supports the benefits of what you do and the costing of what you do is fundamental to getting government to understand that they need to get behind this. I saw exactly the same in the Netherlands when I went there in about 2010/2011. They were all shell shocked, because they’ve always had this brilliant system, everyone knows what midwives do, they had this huge homebirth rate and suddenly they were being attacked because they didn’t have much academic basis to their midwifery, they weren’t evaluating what they did, they had no consumer organisation going. Yet in Australia because we’ve been so oppressed, the way that we have raised our voice when we couldn’t raise our practice was through research and when we got this really good cohort of academic midwives who are now political and who have strong voices who are producing the data. Most of the continuity of care research in the world has come from Australia showing that incredible benefit and evidence.

But when I was at NZCOM (for the conference) I was so impressed with the upcoming researchers. I think NZ has now understands the importance of research and is well on its way, but this is a disadvantage we have when we’ve got a good system, that we don’t get in there and show that that system needs to be maintained.

If you could travel back in time in Australia –what would you have done or is there a key moment you would have picked to bring change stop the removal of birth rights?

Totally. It was 1915 where we had a midwives act and that gave a lot of voice and autonomy to midwives, but then the nurses got a nursing act and they got rid of the midwives act and they brought midwifery under nursing, and they said you cannot be a midwife unless you are nurse first and we train you and we approve you. So, in Australia the oppression and suppression of midwives by nursing began – well intentioned may I say, they’re not evil people – but they honestly felt if you were a nurse first and you were kept under control in a hospital, not doing all this completely unregulated birth at home then that was best. We had a fantastic midwife who used to ride around on a black stallion with her instruments slung over her shoulder. The emergence of the hospital being the clean safe place to have birth ended community midwifery. The nurses were really trying to regulate this by making midwives have to be nurses. We completely squashed and oppressed an entire profession from which we are only now managing to raise our heads and reclaim our voice and our autonomy, and it has been a hard slog and let me tell you the nurses have fought us the whole way.

So, another thing NZ did so well, and this has been the brilliant leadership that you had back in the 90s, they really understood that midwifery needed to stand on its own away from nursing. You’ve done that in every way from regulation through colleges and industrial bodies like MERAS, it’s so important because (nursing and midwifery) are not complementary. Nursing does want to dominate midwifery, Nursing gets very insecure by midwives’ autonomy and strength. I always say to my nursing colleagues, “I don’t get it, why don’t you consider that if we’re stronger, you are too, why do you constantly want to pull us back, to experience the subjugation that you do?

Nobody says “engineers, and motor mechanics” in the same breath. They’re two different professions, and nobody’s insulted by saying they are different. Why is this the case with Nursing and Midwifery?

Many midwives in NZ are feeling like they have reached the end of their tether, they are leaving, there are high levels of burnout, horizontal violence, and poor pay. In your experience, how can we best support our midwives right now?

There’s always a time for diplomacy. My philosophy in life is that there are certain members of our organisation that should be diplomatic – such as the leaders of the college, who get in there and speak with ministers for health and negotiate. But there is also a need for those who are not encumbered by diplomacy.  And that is consumers and strong women and midwives who can do it without threat to their employment and livelihood. We have to get back to the days of chaining ourselves to parliament. It’s not working that we do it all nice and diplomatically, we’ve really got to start saying no, and being loud, and being firm and finding clever ways – and I’ve got to say the NZ midwiveshave done that brilliantly with the Dear David campaign, which was such a clever strategy, the marches, I saw all of that and it was brilliant. But they’re exhausting and they need to be sustained and the worst thing that can happen now, and this is what inevitably happens when you’re working so hard, trying so hard and no-ones listening, is that the profession and sometimes consumers as well, turn in on themselves. Because that is just a gift to everyone to go, well there you go, this proves we really shouldn’t be supporting these people.  You know I always say, if you don’t agree, then have those conversations in house, get your act together and come out united, because tearing each other apart, saying horrible things about each other is never the answer.That’s why the NZCOM Conference Theme was ‘One Voice’ because that one voice is so critical.

It feels like birth choice is often only available to those who have enough money and privilege to access the birth they choose. How can we undo that paradigm?

By making all models publicly funded and publicly available, and then I think it is through education and support, and then it’s through women in the community having homebirths and talking to other women about homebirth and you just see it blossoming out. I think there’s not one strategy or one solution to it, I think it’s multi-faceted. But all through history, I have to say, all through modern history, since we have gone into the hospital systems, homebirth has been generally for white middle class women. They have also been the reformers and the leaders in the revolution for childbirth services. They become so convinced after experiencing home birth, that they’re the ones out championing for their sisters. I think that’s really critical.

For midwives it is so much easier to look after a ‘nice’ white middle class woman who has no other issues, who eats well, doesn’t smoke, and who has no domestic violence in their life. As a midwife, you can understand why it’s an easy call to choose easier cases. But if we’re going to have midwives take on women from disadvantaged communities, and where there is increased social risk, we really have to make sure their caseloads are smaller and we have to make sure they are properly supported, have the ability to properly debrief, and that they have the resources they need.

Due to the medicalisation of birth, there has been a loss of traditional birth knowledge, such as breech birthing skills, monitoring without machinery, and the more holistic care models that look at the whole woman through pregnancy and birth. Do we need to recapture these skills, and if so, how?

I think we urgently need to recapture these skills, but I think we can only recapture them by exiting the institutions that love those tools and develop cultures that see them as mandated. So, for example a birth unit inside a hospital, still has the obstetric bed sitting in the middle of the room, which says “get on me”. We’re still continuously monitoring (in Australia) around 90% of women. There are so many non-evidence-based policies. So, midwives do become de-skilled, and they don’t see it anymore. There is that wonderful paper by Marsden Wagner, “fish don’t see water”.

I worked 20 years in this system, 20 years, and I thought I was a good midwife. I thought I was the best midwife I could be in the situation, but for the last 8 years I’ve worked as a caseload midwife, doing mostly homebirths and I look back now, and I go “yeah, I was a really experienced midwife, in that I had seen and dealt with a lot, but I had to re-learn everything. A woman in her own space, doing her own thing, with her own ideas, is a very different person to a woman that you’ve ruptured her membranes, put her on a drip, put her on a bed, with an epidural. It’s very very different. So, I think the best way to get a midwife’s skills back is to get them out of the hospitals, into the community, to watch women actually birth in their own physiological environment. That’s where you learn it. Of course we need hospitals but that is where women who need that added expertise should be also with good midwifery support as well.

The westernised model of birth in Australia and New Zealand could be considered an expression of colonisation. Can we do anything to unpin the power structures that undermine indigenous birth traditions?

Absolutely, I think New Zealand is leading the way in this. I am sure many Māori people would say there is a long way to go, and I think there is always a long way to go. But one of the things that Australia is now trying to do is the Birthing on Country Project.  Because we have a terrible history, a frankly shameful, shameful history in the way we treated Aboriginal people.  So, the Birthing on Country Project is now happening, it is funded by the government, to bring back birth in the community. Bringing back midwives who work in their own communities, so women can birth in their communities. Historically we’ve rounded Aboriginal women up in their remote communities and, we’ve put them on planes, we’ve flown them to big city hospitals, kept them in hostels away from their communities -which are integral to Aboriginal women – to then give birth with strangers, who are frankly often racist and cold towards them. Then we bundle them up, put them back on a plane and we’ve flown them back to their communities. And you’ve got partners and children who are seeing this woman arrive back with a baby, and there’s this massive disconnect. Canada sorted this out very early with the first nations people. They were flying them all out from remote Canada to the big hospitals, sometimes on an 8 hr flight. And the community said enough. They trained their own indigenous midwives, the midwives stayed in the community. They learnt to triage women who were at risk. Get the women at risk, definitely to the big hospitals but with more culturally sensitive care. And keep the women who don’t have risks in the community. Amazingly as a result, domestic violence dropped. These men now were at the births, and were going “wow, look at my woman, and this is my child.” The tiger, the lion was coming out in them to protect the family rather than abuse it. So, the social meaning and importance of birth has not been grasped enough. I think birth constructs communities, and by not understanding this and not respecting it we can deconstruct, and we can really tear communities apart. We have to understand that where you give birth in a community, can bring a community together.

 

Hannah Dahlen is a Professor of Midwifery and Higher Degree Research Director in the School of Nursing and Midwifery at the Western Sydney University. Hannah has published more than 150 papers and has given papers at over 100 conferences and seminars with half of these being invited keynote addresses. Hannah is one of the top-ranking Western Sydney authors for The Conversation.  Hannah has been cited in the media over 1000 times and has been a part of three documentary films. Hannah has strong international collaborations. She is co-founder of the international research collaboration EPIIC (Epigenetic Impact of Childbirth). In November 2012 she was named in the Sydney Morning Herald’s list of 100 “people who change our city for the better”. She was named as one of the leading “science and knowledge thinkers” for 2012 due to her research and public profile. Hannah has a strong profile in the profession of midwifery. She is a past National President of the Australian College of Midwives, and she sits on several peak National and State committees. Hannah sits on several state and National Health committees. Hannah is still a practising midwife and works in a private group practice in Sydney. Hannah competed her PhD in 2008 and commenced supervising higher degree students then.