Safe Motherhood. It seems like such a simple request. Around the world women and babies still die during pregnancy and childbirth – despite medical advances that could save many of them.
Five years ago, when I began my journey to fight maternal and neonatal mortality, I thought the problem was simple. Today, I see that the health of mothers is affected by more things than the availability of a skilled birth attendant. Like an onion, layers of cultural, socioeconomic and political problems continue to cause problems for women. While we are finding some solutions, we are not there yet.
Layer One: Family
It may be hard to imagine if you are reading this, but there are places in the world where a woman does not have the right to make decisions about her own health. The decision of whether or not she seeks care during pregnancy or birth may lie with her husband, her father, the family as a whole or even the community at large. The decision is based on the cost of care, the perceived need for care and the value of the woman to the society.
Layer Two: Poverty
Being poor in a developed country disadvantages a mother, but being poor in a developing country leaves many women with no options. If the closest health care is hours away, she may feel herself lucky to attend one antenatal clinic, and may simply accept that if something is not right in labor she will have no way to seek help in a timely manner. This is the risk many women take to achieve motherhood.
Layer Three: Cultural Norms
When accessing health care is expensive, accessing health care is the exception rather than the rule. This leads to cultural norms where normal healthy women give birth at home without assistance or with minimal family or community assistance. For many women in the world, this is a sister, mother or another mother from the community who has no training.
This becomes even more difficult in places where women have very little or no value. For example, if her only value is as a worker in the field she may not have the ability to take a day off to attend a local clinic without being considered lazy. Or if a woman is valued most for her ability to bear children, she may not be considered valuable enough for health care until she has proven herself by successfully giving birth the first time.
So women are caught in a cultural trap where the desire for high quality care is weighed against the belief that seeking even basic antenatal care means something is wrong with her.
Layer Four: Social Status
It seems the wealthy and educated look down on the poor and uneducated throughout the globe. This is so ingrained in cultures that we don’t even see it in our own as people laugh at jokes making fun of “country folks” and insult those who have different political ideas from our own because we cannot see why they might feel differently.
In the birth world, I see this through the poor treatment of mother’s within existing medical systems. Doctors and nurses are always educated. The poor women they work with will almost always have less education than them. In societies where status matters (which is basically all of them) there is a feeling that it is OK to treat poor women differently because the poor women deserve to be treated badly.
- You have to yell at them because otherwise they are so proud they won’t do what you say.
- You cannot be nice to them or they will be weak and not labor well.
- She needs to learn how to be tough because she needs to be a good mother.
- She doesn’t know anything and she won’t do what she is supposed to unless I tell her.
Layer Four: Community Resources
Even if her family desires care for her, if the community has no way to provide that care the woman may still have no options. Rural women living in communities without transport to the closest health post may lack antenatal care only because there is no realistic way to get the mother there and back safely. How should the family manage the upcoming birth – send the mother to an area with care before labor begins (paying for her stay of unknown length), or try to create a system that allows for her to access needed care when labor begins (risking not making it to a health post with emergency care in time if it is needed)?
I still wish safe motherhood for all the women of our world, but I no longer think the solutions to these problems are simple. If the solutions were simple, we would have the problems solved already. The truth is, families face difficult decisions when it comes to motherhood. My goal is to help them have more options.
I meet a lot of wannabe midwives, and a lot of midwives. The wannabe midwife I meet most frequently is the one who is angry with the “birth system” and plans to become a midwife to fight that system. Usually, the plan is to become a homebirth midwife to provide for births, “the way they should be.” I like to ask wannabe midwives two questions before I agree that is their path. Why? Because usually they do not realize all the ways to bring change to the system.
Question #1: What is it about the “birth system” that bothers you?
While your first response may be, “everything,” think deeper. Are you concerned about the treatment of women? Are you frustrated with the current protocols? Do you feel research is lacking? Is is restrictive legislation that irks you? It is important to understand what part of the system you feel is broken, and which part you want to fix because the fix for each part is different.
Question #2: How can you have the biggest impact on that part of the “birth system?”
I find wannabe midwives default to the goal of homebirth midwife because it feels like the best way to change what is happening in births. Some wannabe midwives feel it is the ultimate rebellion against a system they dislike. But rebellion can take many forms, and can happen within the system as well as outside the system. Let me share with you a few of my birth heroes who are not midwives to show you what I mean.
Joy Lawn is a pediatrician who was dis-satisfied with the lack of information about neonatal deaths around the world. She fought back with epidemiology by devising systems to estimate the number of deaths and to identify the causes so the public health community could begin to tackle the problem and measure their success.
Barbara Harper is a nurse who uses her skills to help hospitals around the world create safe and gentle birth protocols by collecting and sharing research. She teaches midwives, nurses and physicians the importance of gentle birth and ways they can achieve a gentle birth in their hospital.
Penny Simkin is a physical therapist who uses her understanding of the mechanisms of the physical body to help birth workers improve outcomes through positioning and non-medical interventions when possible. She participates in research to build the knowledge base. Her writings are required reading for many doula and childbirth education programs.
Citizens for Midwifery is a group of parents that advocate for good legislation for midwifery practice. Their work includes collecting and distributing research to local and national legislators while also educating and recruiting other parents to join the work.
EuGene Declercq uses his research skills and knowledge of political science to challenge current beliefs about the American maternity system. His papers point out hidden problems and highlight the importance of midwifery.
I addition to these “big” names, there are many unknown men and women changing the face of birth in the United States and around the world.
I think of the nurses who put in extra hours to participate in quality improvement and protocol committees at their hospitals to succeed in implementing policies prohibiting inductions before 39 weeks.
I think of the peer breastfeeding counselors with WIC programs who are improving breastfeeding success among low income women.
There are many more unknown individuals who need more help to achieve change.
I think of brave souls in insurance companies who are willing to champion the use of doulas, birth centers and homebirth midwives to ensure these services are covered by their programs.
I think of administrators at small hospitals who feel they need to close their birth services due to financial instability, forcing women to travel greater distances when they need care.
There is a great need for change in birth, in the United States and around the world. Where you fit within this change may be practicing as a homebirth midwife, but it might not. We definitely need good midwives. But remember that when you practice as a midwife, you limit the time available to do non-midwifery work and may limit the impact you can have in these other ways. Think of your passions, your skills and what is available around you to determine how to maximize your impact.
I am currently preparing to take the midwifery certification exam. Today I was reviewing intrapartum and was struck with the strange realization that I was on the “other” side of the fence.
When I first trained as a childbirth educator, I had it drilled into me that time limits in labor were arbitrary. Because they were arbitrary, they were useless. Story after story in the natural birth web sphere seemed to prove this philosophy. Doula’s and childbirth educators shared tips on how to know if the time limit you were given was real, or just or convenience. Friedman was blamed for the problem with his 1 cm per hour average, and his theories were thrown out as invalid.
As I reviewed today, I came to the data on Friedman. I realized I’ve grown to respect his philosophy, even if I want better data to make final labor cut-offs. While I was trained to see the Friedman curve as the way hospitals and doctors get patients to do what they really want, I have come to understand the usefulness of a tool to help me ensure labor is progressing. But I didn’t get there immediately, I had some learning to do first. Part of that learning was the importance of the Partogram in global public health efforts. The other part was that I didn’t have the full story on Friedman.
For example, Friedman’s active stage didn’t start until at least 3-4 cm, and it ended at 8-9 cm. which means the 11.7 hours as the upper end of normal active phase for nullipara’s wasn’t the whole picture – in other words, he wasn’t saying 12 hours for labor. The latent phase wasn’t prolonged for nulliparas until it reached 20 hours. 8-10 cm was called the deceleration phase, which wasn’t “prolonged” in a nullipara until 3 hours. Second stage began at 10 cm. So if you do all that math, contractions can start at midnight, and I can reach 10 cm at midnight the next day (24 hours later) and Friedman wouldn’t necessarily call my labor disordered. Second stage had it’s own timing and its own method of assessing progress with fetal descent – a baby that had no descent in one hour needed attention.
The second thing I had to learn was that Friedman was interested in identifying women who were having problems with labor – which I think is a pretty good thing to want to know how to do. While no one wants to say labor has to fit a particular schedule, labor not really progressing well can be an alert mechanism to look more closely at what is happening. Friedman defined several ways a labor may not be progressing well, it may be protracted, or arrested. Each of these had their own timing cut-offs. And the biggest thing they didn’t teach me as a childbirth educator, “falling off the curve” is not an instant intervention as far as Friedman is concerned. There is a four hour wait time before intervening. On the partogram the woman “falls off the curve” at the alert line, then intervention begins at the “action” line.
What is even more interesting to me now is that I realize the response to the “slow” labor is not something arbitrarily chosen. As a midwife, the slower labor alerts me that the patient may have a problem and I assess the situation. Depending on my assessment (is she having regular contractions? are the contractions strong? what position is the baby? ) I will make decisions about most appropriate course of action. Now that I am on this side of midwifery school, I understand why physicians and midwives do not always make the same suggestion. And that even though it looked like it to me before, the management (at least in the cases I’ve been with) is not arbitrary.
So overall, I think I like Friedman’s idea to identify and evaluate women who are far enough away from an average to warrant a high suspicion Now if we could just get some great data on what these averages and upper limits are in natural, epidural and induced or augmented labors.
I’m preparing for two upcoming conferences where I will be presenting. The first is a conference for Christian midwives where I will be providing a clinical update on menopause. The second is a conference for nurse midwives where I will present a poster of my original research. As I finalize my work for these two events, I can’t help but notice the similarities between educating my clients, and educating my peers.
You see, the natural instinct is to basically vomit out all the information you have. Everything you’ve ever read or heard is weighted equally without any regard to who the audience is. This tends to be very long and boring for the listener (trust me, I’ve sat through many really bad student presentations over the last four years).
If you want to really do the best job of sharing information, you need to do a lot of work to determine what needs to be shared, and when. What do I mean?
For example, in the clinical update on menopause I could go deep into the endocrine changes and types of testing available. But since this is a group of midwives who are not infertility specialists, this information is only relevant enough for them to understand that if a client says they had a particular test they know how to find out what that test is. What is relevant is the information women will want from the midwives, and the ways the midwives can help them get that information. For example, we’ll be spending a lot of time talking about menstrual cycles and how they can be used to track progress through the menopause transition. his information help women determine how much longer they probably have to achieve a pregnancy, when they can expect symptoms to subside, and when they can expect that final period.
Next time you are working with your clients, think about what information they really are looking for to make decisions. Make a list of the key things to share and don’t bring up the rest unless they ask. It will save time on your visit and make the clients more likely to listen to everything you have to share with them.
You would think that this in-between time, without a formal paying job and no school, would be super productive. You would think.
I am happy to say that my license is in process with the state, which means I am at least moving forward on one to do item.
And I am also happy to say that I am nearly through with one whole section of the website for updates. Yes, updates. And it is a big one with new navigation schemes and total facelift. I cannot believe I have been working on this for three months already and only have one section *almost* done. As a reminder, some people spend their whole work day maintaining websites. When it is a part time hobby, well, lets just say it takes longer.
I am also happy to announce that we are in the midst of moving. We found a house in the area we need to be and on top of all the other stuff I have to do, I am slowly packing up every speck of dust we own in this two bedroom apartment to be ready for the move. At this point, the day cannot come fast enough for me. This apartment has served us well. And although it is only two bedroom, it is still bigger than the living quarters of many families around the world. Even so, I will be happy to not be disturbed by late night undergrad parties and am excited about the vast space the home promises.
I have my talk for the Christian Midwives International Conference nearly finished. I am doing a lecture with a friend all about menopause. It should be fun, and I cannot wait to see the friends I have missed since starting school.
I have also started posters for two other midwife conferences. It really comes down to the research – if it is worth doing it is worth sharing. So I am doing the work to share. Actually, I have already submitted a paper from the research which I hope will be published.
So, maybe I am being super productive. But with so many projects only part-way done, it sure doesn’t feel like it.
I am in the process of reviewing for my certification exam – the test that will prove I can be trusted by the community to be safe and competent as I work with families to maintain their optimal health. This is such an interesting experience for me as I realize how much I have learned in the past two and a half years, and continue to realize how much more I have to learn. This has also caused me to reflect on my clinical experiences and the things I have learned about being a good health care provider.
I find myself continually pausing at the importance of a physical exam. The sheer amount of information I can obtain about a person’s health by looking and touching. But I live in a society that seems uncomfortable with both looking and touching. These most basic of human interactions are reserved for only the most intimately connected to each of us. Yet, somehow, I must look and touch if I am to participate.
On the one hand, I think of the importance of the midwife being willing to look and to touch. My very fist semester of nursing school I was struck with how difficult it was for some of my fellow students to walk into a hospital room and introduce themselves to a stranger. This seemed such a simple act, but at the same time was felt as such an invasion of privacy. The first clinical learning was to be comfortable taking a step into someone’s private world, to risk being rejected. As a midwife, this step into the private world is even steeper. I ask her to tell me about her most intimate details of her life. How is her menstrual bleeding? Does she have any discharge? Does she have a new sexual partner? The physical exam is also more intimate – STD testing, PAP smear, assessment of uterine enlargement.
On the other hand, I think of the willingness of the woman to be looked at and touched. On some level she is ready for the intimate exchange that is about to happen because she made the appointment, she is here. But at the same time I am most likely a stranger to her. I have only a short time to allow her to trust I will help her achieve her health goal. I have only a few minutes to make or break this opportunity to be invited into her private world – her fears and her brokenness. If I am invited in, she may share things she’s never revealed to anyone. If I am unsuccessful, even my best advice will seem unimportant to her.
As I reflect on the importance of the first few moments of the first visit, part of me wonders if this exchange is easier for homebirth midwives. Does it not seem logical that having more time for that first visit allows for more building of trust? Some of my homebirth midwife friends feel the longer visits are key to establishing a relationship with the mother. But is this relationship built because more time allows for the building of trust; or because the trust is successfully established in the first moments of the first visit, the time allows for a more broad relationship with the woman.
And I begin to wonder how it works when things do not go as planned on that first homebirth visit. When a relationship of trust is not able to be established in the first minutes of the visit, is it then less likely trust will be developed at all? Does more time without this trust cause the woman to feel she cannot be connected, or does it allow the woman the time she needs to be connected. My best guess is that it is different for every woman and every midwife. Personalities are so hard to categorize and people are never “average.”
So then my thoughts return to the world of the nurse-midwife and abbreviated visits. What can I do to be ready to enter her world and be willing to touch…and to help her be willing to be touched.
This will be the last in our series on attending midwifery conferences. Today I want to share my to-do list for conferences – the things I do before and during the conference to make sure I am ready.
1. Know the dates and plan to spend as much time as possible
I find it works best to accept that the time allotted for a conference is conference time. This means I don’t try to sneak in on the last possible flight and miss the last few sessions to get out early. Sometimes this is unavoidable, but the opportunities at a conference make every minute I spend there valuable. Plan around the dates, have work done early and be ready to focus on the conference when those dates come
2. Know the sessions and agenda
This lets me plan out my time. I know before the conference starts which sessions I don’t want to miss, what days I can plan a long lunch or dinner and what nights I expect to be up late. Nothing is worse than realizing the speaker you really wanted to see had a session this morning, and you missed it because you didn’t look at the day’s agenda until you woke up.
3. Stay at the conference
I have found that the money I can save by staying at a cheaper hotel isn’t always worth it. Think about how far away you will be, and if you will be able to walk back to your room if you forget something. Will you need to pay for parking (or rent a car for transportation). Think about how your choice of location will affect your ability to go out to dinner spontaneously or change plans quickly. How will your choice of location affect the amount of time it takes to get to the first session in the morning. Then look at how much money you will be saving and decide if it is really worth it.
4. Make this work time
I’ve noticed that many conferences choose exciting venues, and the temptation is to combine a family vacation with educational sessions. Usually this doesn’t work. Either the family or the conference gets ignored. Your time at a conference is time you are working – educating yourself, making connections. Evening hours, lunch time and the hours when you skip sessions are all important to making that work successful. Speaking as someone who has been on both sides of the family at a conference, if you combine a family vacation and work, you will most likely find that you have not used the conference to its fullest potential or your family is annoyed they spent so many hours waiting for you. If you must combine family and work, set out the schedule ahead of time. Make sure your family understands which days they are on their own and which times you will join them. Think of it as two separate vacations in one hotel room.
5. Pack a bag
Choose a bag that is easy and comfortable to carry. Now place a few key items in this bag. You will need some paper and a writing utensil. A phone, computer or ipad doesn’t count because you will not use those to write a note for someone else. Small cameras can be handy for capturing moments. A small book to read while waiting for sessions — but don’t let this get in the way of networking opportunities. Keep your schedule with you – with the sessions you don’t want to miss highlighted. A map of the venue and possibly nearby restaurants is handy. A water bottle and a non-messy, non-noisy snack help you make it through long sessions. Be sure there is room enough in this bag to put all the handouts and information packets you will get.
So those are my best tips for being ready to make the most of a midwifery conference. Enjoy the conference season!
Remember I told you there were a few things that were not on the list of networking basics. Here they are, and the reasons why I don’t consider them necessary.
Adding everyone you meet to Facebook (or other social marketing tool)
As I’ve said, I’m more of an introvert to begin with. But even if I was not, adding potential business contacts I just met to my personal Facebook account is a bad idea. In the first place, Facebook isn’t a very good contact storage solution. Finding people again in a year or two might be difficult if you can not remember the exact name and need to wade through a couple thousand names. Secondly, if they don’t really know you they might unfriend you after a few weeks of photos of your dog and discussions about your favorite ball team. Why? If they use Facebook for business they are not going to want to waste newsfeed with personal stuff. It’s better to find out if they have a Fan or Business page and connect to that through your business page.
Handing out copies of your business card to everyone
You can do this, and in some industries it is still essential. But don’t feel you have to have a business card to be successful at networking. Building your network is more about who you can contact than who will contact you. Business cards allow the other person to get in touch with you, and in some cases this will be necessary – so always have a few with you. But most of the information you collect won’t be the type for a business card, so be ready to get that information too. And be sure not to let handing out a business card take the place of really talking to a participant and learning about what they have to offer.
Focusing on meeting the stars of the conference
Big name speakers are exciting to meet, but probably not your best networking connections. Why? Usually, everyone at the conference (including you) already knows about their programs and what they have to offer. Meeting and talking to these speakers might be very motivational and inspiring, but is not likely to do much to build your network of new information and opportunities. A lunch with a group of participants you met in the morning session is more likely to give you more new information – provided you ask the right questions.
Attending every lecture
I love hearing the speakers at conferences. I am usually challenged to think about things in a new way or gather some new information. However, if I fill every second of my day with lecture I miss opportunities to meet and talk with the other participants – the key to building a good network. Instead, be familiar enough with the conference agenda to know what speakers you don’t want to miss and what time slots have the least interesting sessions for you. If there is nothing interesting being talked about, find someone interesting to talk to.
Did I miss anything? What networking mistakes do you see people make at conferences?
I will be the first to admit that outgoing and extrovert are not words anyone might use to describe me. Even so, there are times when I need to find the energy to connect with more people, have more conversations and invite strangers to lunch. Midwifery Conferences are one of those times.
It isn’t that I think this is the time to make friends. In fact, sort of the opposite. This is the time to network. I don’t know how you define networking, but I think of it as building a web of information. I find out who is doing what and when, keep track of the key information and move on. And this does an amazing thing for me.
It allows me to discover new opportunities that may be available to me or someone I know.
Did you catch that? It isn’t just about what is possible for me, but what is possible for other people I know too. This is how the web is created. I’m not just collecting information about things I might be interested in, but also listening for what might interest other people. And if something comes up that might be a great opportunity for someone I know, I let them know ASAP so they can investigate it. And this does an amazing thing for me.
It causes people to see me as a source of information.
Yes, my website also makes me seen as a source of information, but this is different. This information is about what’s happening in the midwifery world, who to talk to and where to get volunteers. I become one of the first stops for people embarking on new and interesting projects. And this does an amazing thing for me.
It widens my sphere of influence.
Not only do I learn about projects early, I am also asked to give input on format and who to include on the team. I can have a positive effect on the program without having to volunteer myself because I take the time to be connected to other midwives.
This is all well and good, but you are probably reading this because you want to know, “How do I do this?”
You will work out your own style for the exact particulars, but here are the key principles.
1. Show up and join the conversation. Look at the booths, go to the luncheons, attend meetings. Talk to people about what they are doing, what are their next steps and what is the long term goal. Most people will love to talk about themselves and their projects, so do not feel intimidated. Just ask questions.
2. Keep track of who you meet. Make sure you have a way to find this person in the future either by website, organization, personal email or phone. If you can’t get in touch with this person again, your web has not grown.
3. Keep track of the interesting programs and how to get more information about them. You do not necessarily need to get a “contact name” for each piece of the web. Some pieces of your web may be books, videos, training programs, pieces of research. Keep a list of the key pieces of information you learn about.
4. Have one place to store all the information you find. I say one place because if you have to dig through old files to figure out what that book about a subject was two years from now, you probably won’t find the small note on the bottom corner of your lecture handout. People and organizations are a natural for keeping in a contact directory. You could use a paper list, Pinterest, Amazon lists or other formats for books. You might try keeping a special bookmark folder for important research or organization webpages. Find a way that works for you, so when someone mentions a new project they are starting, you can quickly find the name of the book, or organization, or person that might be helpful to them.
There are some things that are NOT on this list. I’ll talk about them later.
I have a couple conferences come up in the next few months. It made me think about how nervous I was about attending my first conference. I was not sure what to expect, or how to make the best use of the time.
I understood the value of the sessions. I was eager to learn. At that point, I underestimated the rest of the value of a conference. As I progressed in my knowledge, the value of the sessions decreased. If I hadn’t had other reasons for attending conferences, I might have stopped. It would have been a mistake, because conferences have value above and beyond the new learning and ideas I can glean.
So what is the biggest value of attending a conference? The people. While this may be a no-brainer to some, I’m more of an introvert with a few close friends rather than a large network of people I barely know. However, my opportunities greatly broadened as I began to grow a network.
Attending conferences gave me a chance to be around like-minded people. This helped to keep my energy fresh and my interest in birth growing. I do notice that the years I am not able to get away to a conference my work begins to drag.
Attending conferences gave me a chance to be around people who faced problems I had not encountered. This helped me to have a much better understanding of the birth world, and to be prepared for issues that may affect me in the future.
Attending conferences gave me a chance to be around people who solved problems in a variety of ways. This helped me to stay open to new ways of thinking about the issues facing families I worked with and helped me to become a better advocate for families that didn’t see things the way I see them.
Attending conferences gave me a chance to be around people who could learn from my experiences. This helped me to be more open about sharing what I learn and where I struggle.
Attending conferences gives me a chance to volunteer to help promote safe birth. Understanding all the work that goes into a conference or an organization helps me to not judge organizations so harshly when they don’t do what I think they should do.
Attending conferences gave me a chance to be around people who approach the work of birth from many different angles. This helped me to see the wide variety of opportunities available to me, encouraging me to set my goals bigger.
Attending conferences gave me a chance to be around people I love to chat with on the internet. This builds and strengthens friendships that are the backbone of my support system. But it also gave me a chance to be around people I don’t like on the internet. This allows me to see them as a whole person and understand more about their view.
And privately, attending conferences gives me a chance to watch other birth professionals and see what characteristics I like and admire, and which characteristics I want to be sure I do not emulate.
Honestly, attending a conference will do more to help you grow professionally than giving you a few educational lectures. You just need to know how to “work” at a conference – and I don’t mean hiring a table. I’ll share more about that next time.