Gentle Mother-led Weaning

Gentle Mother-led Weaning

 

 

Letting Go

First you hold them like a secret
you only suspect is true.
Then soft knockings from within
tap out messages for you.
Slowly the body allows escape,
you hold them in your arms,
dazed and milky, full of love,
pledged to defend from harm.
Then you  hold them to your heart
and put them to the breast.
but they learn to walk away
like any other guest.

Angela Topping, Musings on Mothering (2012)

When IS the right time to wean?  Before I even start, I need to acknowledge the fact that MANY women wean before they want to, without having met their breastfeeding goals, and often feel like they didn’t have a choice in the matter. This is usually due to a lack of breastfeeding support when they most needed it, and I can understand how articles about women choosing to wean when the breastfeeding is going well might be difficult to read. As a lactation consultant, I hear so many stories from heartbroken women who wanted to breastfeed, but weren’t able to for so many reasons, many of which might have been preventable if they had had the right support earlier in the process. In January 2016, the Lancet published a chilling review of breastfeeding rates around the world, and sadly the UK was at the very bottom of the pile, even worse than the US (which is rather astounding, given that many women only receive six weeks of maternity leave in the US, versus the much more humane 6-12 months that most women get in the UK). In the UK, 81% of women want to breastfeed at the start of their postnatal journey, but by 6 months, the numbers of women successfully breastfeeding have already dropped to 34%, and by 12 months only 0.5% of all women in the UK are still breastfeeding. Which partly explains why extended breastfeeding is viewed as such an aberration in this country.

BUT, if the breastfeeding has been going well, and you’ve been enjoying it and carrying on past the 12 month mark, then at some point the question will arise: when IS the right time to wean? To help answer that question, we can turn to the data. The World Health Organization recommends breastfeeding at least through the first two years of life. Numerous professional organizations, including the Royal College of Paediatrics, UNICEF, the Royal College of Midwives, the American College of Nurse-Midwives and the American Academy of Pediatrics all recommend breastfeeding for at least the first year of life, and then carrying on for as long as desirable for both mum and baby.  New research suggests that there is a link between gut health and brain development, and that nursing well into toddlerhood gives your children a boost in cognitive development and mental/ emotional health. The advantages of extended breastfeeding are numerous and well documented, and carry on well beyond the first year of life. From primate research and indigenous cultures we know that the natural age of weaning for human mammals is probably between 2-5 years of age. If the breastfeeding is going well AND you’re still enjoying it, there’s no reason to stop, and I personally know many, many people who have happily and joyfully breastfed their children until they were 3, 4 or 5 (or even older). I’ve also read and heard so many beautifulbeautiful stories about women who were able breastfeed until the point that their child was ready to stop, a process often referred to as natural term breastfeeding, or child-led weaning.

But what happens if you’re no longer enjoying it? And what happens once you get beyond two years of age? I doubt there’s a standardized answer to that question any more, and I’d imagine that, as with everything, it varies from nursing dyad to nursing dyad. Since I’ve found many accounts of child-led weaning online, but relatively few (if any!) examples of gentle mother-led weaning in toddlerhood, I thought I would share my experience here. The course my son and I ended up charting was a bit different than the one I had originally expected for us, but I am finding a way to make my peace with it.

So, this is the story of how I weaned my second son.

With my first son, I stopped breastfeeding at 15 months. At the time, I had just started a new job as an independent home birth midwife in New York City, and I was convinced that I wouldn’t be able to keep up with the breastfeeding while also being on-call and away at births for hours at a time. Looking back now, the flaw in this thinking seems so obvious to me. OF COURSE I would have been able to continue to breastfeed if I had wanted to, especially as he was only feeding a few times a day at that point, and was fully night-weaned. He would have been fine with a cup of cows milk at bedtime now and then if I was away at a birth, and happy to have a nurse and a cuddle whenever I finally made it home. But at the time, my breastfeeding goal had been to make it to 12 months.  After 12 months, anything beyond that felt like icing on a cake–nice to have, but not really necessary.  So at 15 months, I figured I had breastfed enough, and my (rather self-imposed) perceptions about work pressure convinced me to stop. I weaned him abruptly because I really didn’t know any better.  My husband and I went away for a weekend wedding, and he stayed behind with the grandparents, and when I came back, I didn’t resume breastfeeding him again.  And he rolled with it, of course, because he was only 15 months and couldn’t even talk yet, let alone protest.  But I’m sure he missed it, and I’m sure he would have happily carried on if I had let him, and I’m sure that if he had had a say in the matter, he would have wanted to continue. I was a midwife at the time, but had not yet started down the path towards becoming an IBCLC. I didn’t even know how little I knew.

“Do the best you can, until you know better. Then when you know better, do better.” –Maya Angelou

With my second son, I wanted to do things differently.  I was an IBCLC by the time I was pregnant with him, and I had a much better idea about exactly how important breastfeeding is into the second and third year of life. My goal was to make it to 2 years this time, minimum, and perhaps continue until he was 3 (or maybe even older). I had lots and lots of friends who were “positive deviants” (in the words of Allison Dixon from Breast Intentions), i.e. people who were still breastfeeding their two and three year olds (and in some cases four and five year olds) despite our rampant anti-breastfeeding culture.  Breastfeeding a two year old didn’t seem like a strange idea to me any more. And my attitude had changed as well. Things that I used to worry about with my first son–getting him on the “right” schedule, getting him to sleep through the night (as if this was actually something I could have controlled!), not creating “bad habits”, not letting him “use me” as a dummy/ pacifier–didn’t really stress me much at all with my second. He wasn’t fully night-weaned until 18 months, whereas my first son was night-weaned by 6 months (granted, this was because I was working as a midwife again at 4 months, thanks to the completely INHUMANE maternity leave policies of the United States of America, and I was terrified that I would make a mistake or dangerous decision during a shift because of exhaustion, so the night feeds were phased out quite early). My second son co-slept with us from the get-go. He was in and out of our bed for many months even after he had begun to sleep in his crib. Things were just a lot more relaxed, and he was (still is) one of the most chilled, easy-going and confident kids I know. Of course, I can’t prove that this is because of our more easy-going attitude, or the extended breastfeeding, but in my mind they’re linked.

And then we made it to two years old–huzzah! And the breastfeeding was still going well, and had become a very easy thing to do. As Sarah over at Nurshable points out so eloquently, nursing a toddler is very different from nursing a baby. As the amount of solid foods he was eating began to increase, he began to nurse less frequently throughout the day, and I gently encouraged this by offering liquids, snacks and cuddles during the times that he might otherwise have wanted to nurse. By around 22 months, he was only consistently nursing about twice a day–when we first woke up in the morning and right before he went to bed–plus the occasional emergency nursing session when he had hurt himself or was otherwise having a really difficult time.  But also right around two years of age, there was a change in the way that he nursed which suddenly made things a lot more unpleasant. First, there was a change in his latch. I’m not sure why or how–perhaps it had to do with the changes that were occurring as his speech developed–but suddenly the latch became incredibly tight and clamped. No matter how wide the latch was initially, he invariably changed the shape of his mouth to a very narrow and shallow latch. I tried all kinds of tricks to encourage a wider latch. I talked about it with him, I explained that it hurt, I would take the breast out of his mouth when he did it and re-latch again (and sometimes resorted to just taking the breast away altogether, especially if he had bit me), I switched positions, I used the nipple flip when latching, at one point I even gave nipple shields a try, but as the weeks dragged on, it seemed like this new change was becoming a permanent fixture in our nursing experience. Whenever we finished nursing, I always had a tight little ring of teeth marks around my nipple. He also began the usual (and very normal) nursing tricks that lots of toddlers play–nursing gymnastics where he wanted to nurse upside down and from every conceivable angle, or have his legs on my shoulder while nursing, or his feet in my arm pits. He began twiddling the other side, which I know from my nursing friends and online forums is a very common thing that many women experience and often find incredibly aggravating, and I could usually prevent this by covering my other breast with my hand whenever he was about to reach for it. He did the popping on and popping off game, and talking with a breast in his mouth (ouch!), and ultimately began to want both breasts out at the same time, so that he could switch rapidly between them at his own pace, five sucks from one side, four from the other, then back to the first side again (I suspect my supply must have been dropping a bit at this point, so that he had begun to instinctively switch nurse, which is a great way to boost supply).

Maybe one of two of these changes on their own would have been easier manage, but somehow all of these changes combined meant that I began to approach nursing sessions with dread, and found myself counting the milliseconds until they were over. It wasn’t that it was awful, but it was no longer the cuddly, lovely, snuggly breastfeeding that I had been enjoying prior to this. I began to think that maybe something was wrong, especially as I kept hearing stories from my positive deviant friends about how much they still loved breastfeeding their three or four year old, and how snuggly and comfortable it still was. I began to wonder if maybe they were just having a very different experience to what I was going through, as I usually came away from a nursing session feeling as if I had just been used and pummeled; I often felt annoyed by it, and sometimes I even felt a bit resentful about it, and this was not at all how I wanted to feel towards my child! I also felt a sort of secret shame about these feelings. How could I feel this way, when as an IBCLC I was supposed to be a breastfeeding guru? How could I dread nursing myself, when one of my favorite things in the world was promoting breastfeeding and helping others achieve their breastfeeding goals?  I knew that for many mothers a nursing aversion can be a phase, so I resolved to grit my teeth and carry on as long as I could–in part because I felt like I should be doing natural term breastfeeding, like any good IBCLC would.  If it was a phase, though, we didn’t seem to be coming out on the other side of it, and the months kept dragging on.  I also began to recognise that I was putting a lot of pressure on myself because of the ‘shoulds‘.  If a client had come to me with the exact same situation, there wouldn’t have been any ‘shoulds’ involved at all! I would have been incredibly supportive, and advocated that she listen to her heart and do what felt right to her. And yet, when it came to myself, I had a much harder time letting go of my own (self-imposed) expectations to nurse to natural term.

At about 27 months, I met up with a good friend of mine who was still nursing her five year old son, and in the midst of setting the world to rights, breastfeeding came up. I spoke with her about my aversion towards nursing, and how I was carrying on through the aversion with gritted teeth but not at all enjoying it, and she talked about how she had certainly gone through many phases like this during her long breastfeeding tenure (though never quite as long an aversion as I had experienced at that point). It was lovely because she was able to normalise the experience for me, so that I no longer felt like I was alone in feeling touched-out and resentful towards my child instead of feeling loved-up and oxytocin-blissed out after a feed. But she also said something which I had never really thought about quite in those terms before: nursing is a relationship.  Well, duh!  I was very well versed in all the ways that the breastfeeding relationship is incredibly important to a baby’s bonding and emotional and psychological development and attachment, but I had somehow forgotten that there are always two people in a relationship. I had never quite stopped to think about the ways that my own needs and desires factored into the equation as well. I began to think that I had a say in the matter too; that maybe the right time for us to wean wouldn’t just be when he was ready to stop, but at a point where I was ready to stop, and when stopping wouldn’t be too detrimental to him.  I began to think of it as a compromise between the two of us–I would carry on through the aversion until we came to a point when he could at least be gently persuaded to cut-down and/or stop.

And thus began our very slow and gradual weaning process. I began to think of the entire process as nudging, rather than weaning. I was gently nudging him towards less and less breastmilk, bit by bit, but doing so very slowly, and as gently as possible. For the record, though, this was definitely my idea, not his, i.e. mother-led rather than baby-led.  He would still be nursing right now, if I had been willing to continue. I had to find a middle ground between his desire to continue to breastfeed, and my desire to stop, and hopefully do so in a way that was gentle and respectful of his desires (while still honouring mine).

We began by cutting down the bedtime nursing first, helped by the fact that we have an older child who drinks cow’s milk at bedtime.  It was easy to offer him a little bit of mommy milk first, and then slowly cut-down the amount of time we were nursing, and finish with cow’s milk and books, just like his older brother. There were also a few nights when I was away from him, and he was perfectly happy to have cow’s milk and books with his grandparents or babysitters. He no longer nursed to sleep, and was able to go to bed without me there, so the nursing was no longer the nightly fixture that it had once been. Over the course of a few months, the night nursing became a cuddle and a minute or two of mommy milk, and then occasionally there was a night or two when he didn’t even ask for mommy milk in the first place (and I was operating under the ‘don’t offer, don’t refuse’ policy), so he began to go to sleep with cuddles and cow’s milk, just like his older brother.

The morning feed was a bit more difficult to cut down on. My supply was much larger in the morning than in the evening, and he was in the habit of waking up and coming to crawl into bed with us and having his mommy milk then.  Slowly, though, I began to gradually shorten the length of the feeds, making it up with lots of cuddles and persuading him to come down to the kitchen with me for a drink of almond milk or cow’s milk while continuing the cuddles. Over time the morning feeds became shorter and shorter affairs, finally down to about 5 minutes in the end, but I began to realise that he wouldn’t voluntarily give them up.  I decided I would probably just need to pick a date, and work towards it. Knowing that he couldn’t keep more than a week in his head at one time (his concept of time is still rather shaky), I began to count-down the days with him. Every morning, as we were breastfeeding, I talked with him about how much bigger he had gotten. I talked to him about all of the things he was capable of doing now that he couldn’t do when he was a little baby. I talked to him about the foods and drinks he could enjoy now that he was so much bigger.  I talked about how his older brother had had mommy milk for a long time too, but that eventually as he got older he began to drink cow’s milk instead of mommy milk. And I talked to him about how much I had enjoyed breastfeeding him, and how special it was to me.  And at the end of these little conversations, I explained how we would be stopping the mommy milk in six days…four days…two days…tomorrow. He took it all in stride, and began to count down with me (“no more mommy milk tomorrow” etc.), but of course I wondered how much he actually understood what that meant.

And then, the day finally arrived. “Tomorrow” became “today”, and when he crawled into bed with me in the morning, I explained that the mommy milk was finished. He cried, of course. We both cried. But I held him and talked to him again about how much I had loved breastfeeding him, and about how sad I was that it was over, and about what a special time it was for both of us. And then I talked about how much I love him, and all the ways that I can still comfort him, with cuddles and snuggles in bed, with hugs during the day, with stories on my lap, with kisses when he hurts himself, with tickles and sniffs and rough-housing. And he was comforted, in the end, and we went downstairs to get him some almond milk or cow’s milk, cuddling all the while.

That wasn’t it, of course. He continued to ask for mommy milk in the coming days, but there were fewer and fewer tears involved. We had the same conversation many times, about how lovely the breastfeeding had been, and how it was sad that it was over, and all the ways I could still comfort him, and how much I loved him. And we had lots and lots of cuddles, to try to make up for it, but I have to admit that he was a lot clingier than he normally was for the first several weeks. I felt incredibly guilt-ridden about my decision. Also, in retrospect, I realize now that I could have picked a better time to do this, as I ended up weaning him about 2 months into starting my midwifery course, which meant I was no longer around as much as I had been before. It was a big adjustment for him—to end our breastfeeding relationship at the same time that I was also away from him for the first time—and it would have been an easier transition if I had held on for just a little while longer, giving him the comfort of nursing through my transition to school.

But, after these first few weeks, he did begin to find his equilibrium again. He sometimes cheekily asked for mommy milk at random times throughout the day, even asking for “bonus milk” at one point, which I think was a way of testing me to see if there were any loopholes in our new relationship. And one morning many weeks after the weaning, while I was getting dressed in front of him, he plaintively asked if he could try one more time, and without giving it much thought, I let him. I was curious to see what would happen. He was amazed and delighted that I had relented, and gave it proper go (he still had his latch, for the record), but the milk was no longer there. After a few sucks on one side, then a few sucks on the other, he declared that “the milk was all gone.” And since that day, he’s asked for it a lot less (although he has also suggested that we should have another baby, so that the mommy milk will come back). He’s also asked to put his hand on the “milks” a few times when he’s snuggling me and wanting comfort, which I’ve let him do.

And so, at 31 months of age (2 years and 7 months), we ended the breastfeeding chapter of our relationship. Even preparing for it as I have been, even talking about it and cherishing the last few weeks of it (amidst the gritted teeth and sore nipples), even wanting it to end, I have been amazed at the mix of emotions this has caused in me. It’s been incredibly bittersweet. I have been simultaneously incredibly proud of him, and also crying inside, particularly as he’s my last baby, and I’ll never breastfeed again. In some moments, I feel inordinate relief that it’s over. In other moments, I feel incredibly guilty about it, particularly in the moments when he’s being clingy. Like so many things with motherhood, there is a lot of self-doubt and uncertainty. I wonder if I made the right decision, I wonder if I should have held on for longer. These things keep me up at night, sometimes. But by and large he seems to be taking it all in stride, and aside from the initial clinginess, he’s returned to his normal, happy, relaxed self. We keep having lots and lots of cuddles, and still talk about it now and then. It was a beautiful, magical time in our lives, and I knew, even as it was happening, that it wouldn’t last forever. Now that it’s over, we’ve moved on to the next beautiful, magical time in our lives (as these toddler years are also way too brief). Our relationship continues to evolve and grow, as it always will, and I will weather these changes as he grows up and needs me less and less. But for now I still sniff his head (which still has that sweet, intoxicating baby smell now and then) and watch him when he’s asleep (he still looks so small) and marvel at all of the new things he’s learning and doing every day (he’s begun asking about using the potty like his older brother, so I can guess what’s coming next). The days are long but the years are short, and the seasons of motherhood continue on.

Notes to Self

Notes to Self

We’re beginning the clinical portion of our midwifery education now, after a very intense, action-packed 8 weeks of theory and classroom work. For the next 8 weeks, we’ll be in the clinical setting, on our placements, learning by doing, helping and shaping the antenatal, birth and postnatal experiences of the women we meet.  I’m SO EXCITED to begin actual midwifery work again! But on the eve of my clinical placement, it seemed like a good time to write a few notes to myself (and my fellow students on the eve of this exciting milestone):

Clinicals are going to challenge you in ways we can’t even imagine yet–even though you’ve done parts of this before, it’s still going to be challenging, and new. You’ll need your mind, your ability to think, your ability to feel, your ability to see clearly, to watch and wait, to put 2+2 together, to use all of this knowledge we’ve been working so hard to acquire.

But remember that birth isn’t in the textbook. It’s in the mother, sweating with exertion, it’s in the partner, whispering words to encourage her, it’s in the baby, liminal and waiting.

Remember that wherever you stand in that labour room, no matter how chaotic, you stand in a holy place. Your heart has called you to this profession, this path, this work. Let your heart shine–your wisdom, your strength, your love.

 

 

Differences so far…

Differences so far…

Wow, I’m not even sure where to start here. There have been A LOT of differences so far between American midwifery and British midwifery. Here’s just a small sampling.

First, abbreviations. Some of them are the same, most of them are completely different. In the US, an IUD is an intrauterine device (i.e. contraception). In the UK, it’s an intrauterine demise (stillborn baby). BIG difference there. In the US, taking a medication twice a day is BID (“bis in die”, Latin for twice daily); in the UK, it’s just BD. QID = QD, TID = TD. In the US when I see PE on a chart, I would think Physical Exam. Here it means Pulmonary Embolism. In the US, contractions are measured on a tocometer, or abbreviated as “toco”. Here it’s abbreviated as CTG (meaning cardiotocograph). FHHR is fetal heart rate heard regular, rather than just FHR (Fetal heart rate). Small things like that, but it adds up.

The antenatal visit schedule is very different as well. In the US, pregnant women can get anywhere from 12-14 prenatal visits through the course of their pregnancy. Here, a nulliparous woman (first-time mom) will only have 10 visits total with her midwife, and a multiparous woman (second-time mom) will only have 7 visits total with her midwife. In the US, generally the longest time between visits would be 4 weeks, but here there can be up to 6 weeks between midwifery visits. I can see how this might be a much more efficient schedule and use of resources (and the NHS is all about using resources wisely), but I wonder if there is flexibility in this schedule for the mums that may have a lot of issues going on and might actually needs more frequent follow-up. I wonder how that works with the overall schedule, and I wonder how midwives get around that (extra sonograms in place of visits, maybe?). This will be a very interesting area to learn more about. According to NICE guidelines for antenatal care, the schedule looks like this: Initial booking appointment with the midwife by 10 wks if possible, 10-14 wks: ultrasound for gestational age (but no midwife visit), 16 wks: midwife, 18-20 wks (ultrasound for fetal anomalies/ anatomy scan, but no midwife visit), 25 wks: midwife (nullips only), 28 wks: midwife (nullips AND multips), 31 wks: midwife (nullips only), 34 wks: midwife (nullips & multips), 36, 38 wks: midwife (nullips & multips), 40 wks: midwife (nullips only), 41 wks: midwife (nullips and multips, to discuss postdates options). And that’s it, folks.

The screening schedule is slightly different. For instance, in the US an initial visit usually involves a pap smear and a test for gonorrhea and chlamydia. Here in the UK, these are not routinely offered. Pap smears are done routinely by a GP (rather than OB/Gyn or midwife or women’s health NP) on a different screening schedule (every 3 years), so  there’s no need to try to catch up on smears at an initial pregnancy booking. In the US, since many women don’t have access to routine care, it’s sometimes been years and years since they had a pap smear (and sometimes they’ve *never* had a pap smear before), and because pregnancy is actually a time in a woman’s life when she accesses care, the US system is designed to try to take advantage of this and do a lot of catch-up primary care/ health promoting tests at the same time as the routine prenatal care. But thanks to the beauty of UNIVERSAL health care, routine health promotion practices are already in place, so pregnancy care is exactly that: *pregnancy* care. Also interestingly enough, there is no vaginal/ pelvic exam at an initial pregnancy visit here, and many of the British midwives I have spoken to are very puzzled by the need for one. “Why would you routinely do an invasive, uncomfortable exam at an initial pregnancy booking on all women?” Well….because….well….I don’t really have a good answer to that. Because in the States this is something we’re taught to do: pap/ gonorrhea+chlamydia test/ vaginal exam/ bimanual exam/ pelvimetry, at every initial antenatal visit. But in a healthy, low-risk woman who’s already had access to regular check-ups and care, is all of that really necessary? Paps are routinely screened for in the general public by GPs here, and there is a national screening program for all women under 25 years of age for chlamydia, so again chlamydia is already being routinely screened for in the most at-risk population. There is no mention of gonorrhea testing as a routine part of antenatal *screening*. I guess this means that GC/CT are screened for only if there is an indication through the woman’s personal history? Again, this is something I’m going to have to learn more about. Also very interesting is the fact that Group Beta Strep is NOT routinely screened for in all pregnant women at 36 wks here. Which is rather mind-blowing to me. But in a less litigious, more resource-efficient society, perhaps this makes sense too. And it would drastically cut down on the overuse of antibiotics and antibiotic resistance (not to mention the damage routine antibiotic use is doing to our collective human microbiome on a population level). Again, this is something I’m going to have to learn a lot more about.

And finally, ANATOMY is different here. I kid you not! I thought surely the Latin names for muscles and bones and organs and structures would be the same. But no, lots of new names I’ve never heard of before. For example, I would call it the rectouterine pouch. Here it’s call the Pouch of Douglas. What I would label the pubococcygeus muscle (in the levator ani), the Brits call the pubovisceral muscle. What I would call the puborectalis (again in the levator ani), the Brits call the puboanalis. Lots and lots of little things like that. Very similar, but not quite 100% the same. Which means that even though a lot of this material is familiar, I can’t assume that I know it. I don’t know it (and I had forgotten most of the names of all of these muscles anyway). So I am having to study it all again as if I’m learning it for the first time. Time to hit the books!

 

Sleep and “Self-Soothing” Roundup

Sleep and “Self-Soothing” Roundup

There is so much conflicting information out there on sleep, and so many messages you’ll hear on why having your baby “sleep through the night” is the holy grail of parenting and that if your baby isn’t hitting this milestone by (insert whatever age you like here), it’s a disaster or they’re not a good baby or you’re not a good mother or you’re allowing them to create bad habits etc. etc.  But the truth is that every baby is unique, sleep needs vary tremendously between kiddos, and learning to “sleep through the night” is a developmental milestone that you can’t really force a baby to hit before they’re ready, just like you can’t force them to sit up or crawl before they’re ready. Also, it’s important to remember that even as adults we wake up several times in a night (because we’re thirsty, or hot, or cold, or have to use the toilet, or had a bad dream, or heard a loud noise, or are stressed about something, or uncomfortable, or or or…), but the difference is that as adults we have learned to roll over, self-soothe and go back to sleep. Babies are still learning this skill.  It takes years for them to fully master it, and until they do, they often still need our help, input and reassurance to fall back asleep. Meeting a baby’s needs is not “creating bad habits”; it’s being responsive and attentive to the baby’s needs, which in the long run will create more security and independence.

Strangely enough, discussing sleep and self-soothing is a very “controversial” topic. On parenting boards and facebook groups and public forums, there are strong advocates for sleep training, using either “controlled crying”, “gradual extinction” or “crying-it-out” (CIO) methods as a way of teaching a baby to sleep through the night. There are equally strong advocates against these methods. Because every parent is exhausted (EXHAUSTED!), there is an unending market for books, sleep gurus and training methods as desperate parents (understandably) look for ways to get more sleep. And not surprisingly, the message you get from mainstream sources, news articles and “how to get your baby to sleep” books suggest that a baby who isn’t sleeping through the night by (insert whatever age you like here) is a problem that needs to be fixed. But what I am more interested in looking at is the actual science behind these differing approaches. Research into sleep, such as what Professor Helen Ball at the University of Durham is doing through the Infant Sleep and Information Source, is still a relatively new field, but there is a growing body of evidence which is beginning to refute the claims of the many (insanely popular) sleep experts and authors and gurus who recommend this or that sleep training technique.  The following is a round-up of some of these articles.   

First, Sarah Ockwell Smith has a great article on realistic sleep expectations for babies. As you can see, there is A LOT of normal variation in this, and even if one baby is ready to sleep through the night at 8 months, another baby might not be ready to do so at all. Each kiddo is unique and has different needs. 

Sarah Ockwell Smith also has a good article on what’s really happening when you teach a baby to “self-soothe”. Unfortunately, sleep training methods don’t really teach our babies to self-soothe. This is a developmental skill which they can only learn with time and maturity. Instead, it teaches a baby to stop signaling her distress. Babies are smart and they very quickly learn that if crying doesn’t bring a response, it would be better to conserve their energy instead and not use a method that doesn’t work. A study done in 2012 by Middlemiss et. al. monitored the cortisol levels (i.e. stress levels) in 25 mom+baby pairs and found that at the beginning of the study, the mom and baby were synchronised in their stress response, meaning that when the baby was stressed and signaled this to the mother, the mother responded to this with a rising cortisol level of her own. In other words, if baby was distressed, mom was distressed, and their cortisol levels were in sync. By Day 3 of the study, after using a gradual extinction sleep training method, the researchers found that the baby was no longer exhibiting stressed behaviour, but the baby was still distressed (as demonstrated by high cortisol levels). Meanwhile, because the baby was no longer signaling its distress, the mom’s cortisol levels had decreased, indicating that she was no longer in sync with her baby (at least in terms of cortisol levels).

Calm Family wrote a very detailed response to the BBC One’s recent airing of Panorama, Sleepless Britain, which addresses many of the ways “sleep issues” are portrayed in the media.

The Analytical Armadillo, another IBCLC blogger, has also written a good analysis on what happens during self-soothing, and that even though it works (and it does work), it’s not necessarily harmless.

Evolutionary Parenting looks at the science behind exposing our kids to stress, and what’s actually going on neurochemically in their brains when this happens. 

Uncommonjohn also looks at the science behind self-soothing

The Milk Meg writes about the many reasons our babies wake so frequently in the night.  

And while this doesn’t actually get into the science behind it, Mama Bean Parenting documents quite…succinctly…the many, many, many messages we receive in our society which tell us that a baby that doesn’t sleep through the night is a “problem”.

Finally, Dr. Sears has some good suggestions on ways to get more sleep without using CIO methods, as does Dr. Jay Gordon in this article. The Milk Meg also has some ideas on ways to gently night-wean breastfeeding babies.

And one final disclaimer, since I know this is an incredibly sensitive subject for many parents. I understand the desperate need, the overwhelming desire, to somehow find a way to get more sleep! We’ve all been there. Many of us are still “there”.  Parenting is exhausting, and waking frequently with our babies in the night is not at all conducive to our modern lifestyles. I absolutely get it. And I have many clients and friends who have used sleep training methods, sometimes with very good results–hell, I’ve attempted a few of these methods myself with my first son out of sheer desperation (but wasn’t able to follow through with them). I am in no way judging the reasons why parents might turn to these methods, and I have nothing but empathy for the desperate exhaustion that makes these methods seem like the only answer. Getting more sleep is a positive thing for everyone involved, and allows us to be better parents, and in our bleary, sleep-deprived states figuring out how to get more sleep seems all-consuming and anything promising a quick fix seems like mana from heaven. But it’s important that we as parents do careful research and make informed decisions before deciding on a parenting course of action. Our media and society is saturated with messages about sleep and ways to “fix” it, and nearly all of these messages usually recommend some form of sleep training. That is one side of the debate. All of the articles I have posted here are the other side. It’s important to understand both sides before making an informed choice.

As a midwife, asking “Is your baby waking regularly and feeding regularly?” is a much more supportive and useful question for new parents instead of “Is your baby sleeping through the night?”. Most likely, a normal and healthy baby who’s feeding regularly and growing well will NOT be sleeping through the night, so rather than make parents feel like there’s something wrong, it’s much better to emphasise what’s absolutely right about this scenario. And then look for other ways to support exhausted parents to sneak a bit more sleep into their lives.

Sealing Birth

Sealing Birth

I’ve been finishing up the requirements for a Sacred Pregnancy Belly Bind and Sealing course which I started years ago, but was never able to complete thanks to the birth of my second son, which threw me for a bit of a loop. Two years later I’m finally coming back to it again, and have been enjoying it very much. At the heart of the course are the skills needed to do a bengkung belly bind (pictured below), but the course is about more than just the physical binding itself. It’s also about learning how to create a sealing ritual to honour the birth and provide closure for the woman, as well as supporting her through her postnatal journey–both of which are sorely lacking in our modern world!

Pregnancy and birth is all about opening, on so many levels: opening yourself physically, opening yourself spiritually and emotionally, opening yourself up to the vulnerability of a new and powerful love, and opening yourself mentally and psychologically to the needs of another human being (and being willing to put those needs first). Our western culture is fairly good at discussing the physical opening that takes place (just go to any childbirth class or antenatal prep class and it will be all about the stages of labour and dilation and what happens to your body), somewhat good at acknowledging the mental and psychological opening that takes place (but better at focusing on the baby’s needs than on the mother’s needs), and generally not so good at the emotional or spiritual opening that’s going on. Antenatally, there is the tradition of the Baby Shower (very popular in the US, much less so in the UK), which revolves around gift-giving and providing for the material needs of the baby but tends to gloss over the emotional or spiritual needs of the mom and the transition she’s undergoing. A Mother Blessing, based loosely on a Navajo tradition known as a Blessingway, is a newer tradition that’s been growing in popularity and does a better job of filling the emotional and spiritual void by honouring the mother and her journey and showering her with love and blessings from her community. However, this still pertains mostly to the antenatal time period, and is focused on the birth itself. Overall, in our modern society, very little attention is given to providing closure for women, helping them to ground and center themselves again after such a transformative experience, and acknowledging their new role as a mother. That’s where a sealing ceremony comes in.

After an opening, it makes sense that there should be a closing. A woman needs to be sealed, on so many levels. Physically, her womb and pelvis and pelvic floor need to contract again, after softening and expanding and dilating. Her abdomen has to knit together once more after the diastasis recti muscles have literally come unzipped.  Her blood volume shrinks and her blood pressure may rise again (slightly–this is normal, and has nothing to do with the stress of having a newborn!).  On a chi/ energy/ prana level, she has to re-balance herself and find her own, singular energy rhythms again, after having adjusted to holding her own chi as well as that of her growing baby.  Emotionally, she has to adjust to the sudden emptiness inside of her, after having grown used to sharing her body and feeling the baby’s movements inside her for months and months.  And even more importantly, she has to adjust to being the only occupant of her body again, reclaiming herself as a single entity, and feeling the wholeness of herself once more. Spiritually, she is going through perhaps one of the biggest transitions of her life, from maiden to mother, with all of the new uncertainties, vulnerabilities and identity upheaval that contains. It’s a very big deal–SO much is happening on so many levels, but in our western culture there is no formal way to acknowledge or honour this process.

Many traditional cultures around the world have sealing ceremonies and traditions which are an important part of the postnatal process. In China, new mums are encouraged to stay in bed for the first 30 days and are fed “warming” foods, often with lots of ginger and bone marrow in them to help . In India and traditional Hindu cultures, women remain home with their new baby for the first 40 days to help promote breastfeeding and avoid infection (interestingly enough, it takes about 6 weeks for a woman to fully establish her milk supply, which may be the underlying reason for this), allowing family and friends to care for her while she learns to care for her baby.  Bengkung binding traces its roots to Malaysia, where it’s part of the traditional postnatal care offered to women. But of course, in modern America and the UK, there’s often very little room made for the woman’s transition during the postnatal phase. The focus is very much on the baby. The early weeks of the postnatal period involve trips to the paediatrician (in the US) or home visits by midwives and health visitors in the UK, checking the baby’s weight gain before finally discharging the mother/baby dyad from care around Day 10. Well-intentioned family members and friends encourage the mom to “get her life back” or “get her body back”, set up feeding schedules and routines for the baby and attend baby classes and postnatal groups as a way of socialising, all of which require the mum to leave the house with her newborn at a time when she’s not fully confident in her new identity yet, and often still overwhelmed by the transition and the round-the-clock needs of her baby.

And of course, we’re getting it wrong again and again. For one thing, very few women are recovering from a peaceful or empowering birth in the first few weeks.  Most are having to process and contain experiences that ranged from disappointing to outright traumatic.  As a midwife and lactation consultant, part of my job is to listen to women’s birth stories. Often I’m visiting with women in the first few days or weeks after the birth, when the experience is still very raw and they’re still processing it. Asking them to share their story can sometimes open floodgates of emotion for them, particularly if the birth was traumatic to them. A big piece of my job is to give the woman time to tell her story, in her own words and at her own pace–not just to share the details of it for the purposes of collecting her medical history, but to give her a chance to debrief. Even if she’s already told all of her friends and family about her experience, there’s something different about the listening you do in the role of a birth worker. It’s important to give her space, without judgement, and to acknowledge her experience. Sometimes sharing her story will bring up questions about it that she didn’t even know she had, which I’m sometimes able to help answer (particularly if the question is about something technical), and sometimes not (but sometimes just being able to formulate a question for the first time is helpful). Other times she doesn’t have any questions, but will simply repeat something over and over again, usually until it’s acknowledged (and here, echoing the woman’s words back to her helps tremendously; she might say at 6 different points in the story that she hadn’t really wanted to be induced, and saying a statement like: “You really didn’t want to be induced” allows her to feel like she was heard). There are many counseling tips and tricks that you pick up along the way, such as active listening, asking open-ended questions, reflection, paraphrasing, summarising and clarifying etc. But the root of it, of course, is listening without judgement, and holding space for her to be or feel whatever is coming up for her. This is an important part of sealing a birth, and can be very healing for a woman.

Mothering is incredibly invisible and unappreciated in our society. In other cultures, mothers are respected and honoured on a fundamental level which we seem to be missing. So much of our identity comes from what we do professionally. Just think of a dinner party with new acquaintances where everyone is going around asking you about “what you do”. When I was not working professionally but rather staying home with my children, I would often respond to these types of questions with something like: “Oh, I’m just a mother right now” (JUST a mother…), or “Not much”.  Not much! As if the enormity of my daily work–caring for my children, nourishing them with my body when I was breastfeeding, preparing and cooking meals for them, running the household, doing laundry, cleaning, grocery shopping and a gazillion other domestic chores, but more than anything else teaching them *constantly* by my words and actions and attitudes–amounts to nothing much at all because at the end of the day I had very rarely achieved anything, at least anything that could be crossed off of a to-do list or recognized by the wider culture as important.  The work is repetitive, monotonous, lonely and under-valued, and in our culture it’s very low-status work. One has only to read a book like What Mothers Do by Naomi Stadlen to see the damage this lack of status inflicts on women on a daily basis. Here we are working our guts out, but the idea of a stay-at-home mother in our culture connotes the idea of not doing much of anything (but actually, this applies to any mother, because even working mums still have to come home from their paid job to begin their unpaid job of mothering, and are most likely only recognised for the work they do as part of paid employment). And we wonder why women are suffering from postnatal depression and anxiety in higher and higher numbers, or why modern women today are struggling as much as they are find their way.  The author of this article eloquently points out that perhaps feminism has let women down on this front. I agree with that, but I also think it’s part of a wider malaise in our society: raising children and parenting the future generation is not seen as important, meaningful work, and this is a problem.

Which brings us back to sealing birth…rather circuitously.  We need to get better and sealing birth for women. We can do this formally, through a ritual like the one Sacred Pregnancy has created (or something that we create on our own), or informally through birth debriefing, but at it’s very heart sealing a birth involves acknowledging the transition she’s been through, recognising the incredible work she has done and is currently doing–the work of giving birth, which is in itself a monumental achievement, but also the ongoing work of mothering–and honouring her for this. Sealing birth won’t elevate the status of motherhood overnight, or fix the many deficiencies in our culture, but it can definitely help to make a difference on an individual level to the woman herself. And every woman who feels supported, recognised and honoured as a mother will bring that confidence to her vital and incredibly important job of raising the next generation, and shaping our society in the process.

Looking back, I think that I was very lucky in that I was able to seal my first birth pretty well. While I never had a formal ceremony done, I was lucky to have had a very empowering birth experience (I’ll get my two birth stories posted soon) and I happily recounted my birth story over and over and over to whoever would listen. I felt like superwoman–I felt like I could do anything, after having given birth! There was something about repeating it again and again, something in the telling of the story, that helped make it real for me, and helped me gain closure on it. The telling of it and the closer helped to translate the confidence I felt about my birth into a growing confidence I felt about my new role of as a mother (Breastfeeding? Pshaw! OF COURSE I can breastfeed. I just gave birth after all–I can do anything!) I also had loads of support and help from friends and family in the first few weeks after my first birth, which made it a relatively smooth transition. With my second birth, this wasn’t the case. Even though the birth itself was wonderful, joyous and empowering, the postnatal period became incredibly stressful due to a medical emergency with my 5 day old son, which threw everything off kilter. Also, since it was the second time around, my expectation was that of course I would be able to manage it, just like I had with my first…but in reality, I found the transition from one child to two children incredibly difficult!  And perhaps not surprisingly, I suffered from postnatal depression with my second son (again, I’ll share the story on here sometime soon). I think sealing is crucially important part of the birth experience. Was your own birth sealed? And if so, how was this accomplished?

 

Bengkung belly binding

 

 

Day One and Two: Full on!

Day One and Two: Full on!

Hello lovely readers: guess what? I’m in midwifery school again! And trust me, I never thought re-qualifying was going to be a walk in the park, but these last two days have been a pretty brusque reminder to just how intense this is going to be. And I know I’m capable (and thankfully, a lot of it will be familiar, at least), but man–here we go!

Yesterday was a general orientation to the program: the course requirements, the timetable, our first assignments. Thursday is a day-long orientation to the library, where I suspect we’ll be spending *a lot* of our time. We’ve received an independent study guide, a workbook on medications and abbreviations and prescribing in labour, and an inch-thick workbook on reproductive physiology, plus some fervent warnings to keep up with the work and not let it pile up. Right! We also spent yesterday and today working in small groups, getting to know each other, and discussing the role of the midwife and the principles of midwifery care, which is always nourishing and enriching work.

The class itself is fabulous–there are 28 of us in total, ranging in ages from 18 and fresh out of sixth form (sort of the UK high school equivalent) through late 40s with teenager children, all from very diverse cultural and social backgrounds, and with a myriad of reasons for wanting to be midwives. I was very relieved to discover that I’m not the only mature student, by a long shot, and not the only mother going back to university with children at home. In fact, most of the other mothers in my class have three children rather than just two, and a few of them even have four children (and one with a set of twins), so if they can do it (superwomen!), I can too. I made a comment along the lines of “wow, how do you do it?” to a mum of four in my class, and her response was “You just have to get super organised.” Right! Wise words; that is definitely the plan! We’re still just getting to know each other, but everyone seems very friendly and welcoming so far, and I suspect that the wonderfully stressful bonding experience we’re all about to go through will ensure some lifelong friendships. I still think of my midwifery school friends from my US qualification with such love and warmth, and even though most of us don’t talk or hang out much any more, I still feel like many of them are my sisters as much as friends and colleagues, and the feeling hasn’t faded through the years, despite the distance and limited contact (mostly through facebook these days). So there is definitely something to be said for midwifery school friends!

Tomorrow is our orientation to our clinical site. My first rotation will be community midwifery, which is an area I’m very excited to learn more about, as it doesn’t exist in the United States. At all. In fact, the UK’s commitment to community midwifery is a bit of a rarity even among European countries, and is very exciting. My limited understanding of it so far (I’m sure I’ll have a much better grasp of it in the weeks and months to come) is that community midwives are responsible for delivering midwifery care in womens’ homes. This includes providing home births, of course (which is my particular love, and where I want to be practicing when I finally graduate again), but the more remarkable feat of community midwifery is that here in the UK, ALL women (even those who delivered in hospitals) are given follow-up postnatal care by a midwife in the comfort of their home, usually 1-2 days after returning from the hospital, then again around Day 5-6 postnatally, and finally one more time around Day 10 when the woman and baby will finally be discharged from midwifery care. Let me say that again, because it still sounds so incredible to me: a midwife will come to your *house* in the first few days and weeks after you give birth, check your bleeding, help with breastfeeding, weigh the baby, perform the newborn screen etc. etc., and this is not some extra, luxury service for wealthy clients with private insurance, but ROUTINE POSTNATAL CARE.  In the US, postnatal care generally looks like this: you give birth, you’re seen in the hospital by a midwife or OB on postnatal Day 1- Day 2 (which is usually when you’re discharged if you’ve had a vaginal delivery; usually Day 3-4 if you’ve given birth by cesarean), and then…that’s it. Your next postnatal visit is booked for 6 weeks later. And to a new mom with a newborn baby, the chasm between Day 2 and 6 weeks might as well be the Grand Canyon. SO much happens during those first 6 weeks–so many questions, such a steep learning curve–and you’re basically on your own for most of it (unless there’s a rare complication that would necessitate an earlier visit). Add to this the fact that many women in the US are also expected to return to work around 6 weeks, and maybe it begins to sink in just a little bit how cruel and inadequate the US maternity leave/ postnatal care system is.

Which isn’t to say that UK postnatal care is perfect.  In fact, most of the complaints I’ve heard since I’ve been working as a lactation consultant here for the past 3 years is that postnatal care isn’t nearly supportive enough, and that the advice about breastfeeding in particular can be very inconsistent. Also, one of the reasons community midwifery follow-up happens so quickly here is because many women are being released from the hospital within 6-24 hours after giving birth, which can also be very disorientating and stressful, for first-time moms in particular, I think.

In any case, I am very excited about working in the community initially–and I’m even hopeful that I might be able to attend a home birth, if I’m lucky. Fingers crossed! But our clinical rotation is still 8 weeks from now, and first…there’s a whole lot of reproductive physiology to review.

Breastfeeding News Roundup

Breastfeeding News Roundup

Breastfeeding has been in the news a lot the last few weeks. Here’s a quick roundup of some of the most interesting and exciting new articles regarding our first food, and why it’s so important.

First, a viral post about the microbiology research of a Vicky Green, a Biosciences student at South Devon College, who demonstrated the power of breastmilk by placing it in petri dishes cultured with some of the nastiest bugs around, including MRSA and E. coli. In the picture in the link, you can actually see clear rings surrounding each drop of breastmilk on the petri dish where the bacterial growth was halted by the breastmilk proteins. What’s even more remarkable is that she’s using the breastmilk from a mum nursing a 15 month old and a mum nursing a 3 year old, which just goes to show that breastfeeding DOES continue to play an important and vital role in nourishing our children and providing optimal health for them well past the first 6 months of life. Unfortunately, as an IBCLC, I hear all too often from clients that they were told by a (presumably well-meaning) GP or Health Visitor that there’s no benefit to nursing a baby past 6 months. Absolute nonsense, as this research so clearly demonstrates! And who knows, perhaps the protein in breastmilk will hold the key to defeating bacteria like MRSA in the future.

And speaking of nursing babies beyond infancy, Tamara Ecclestone recently posted a lovely photoshoot of herself nursing her 2 year old daughter Sophia and just about broke the internet in terms of controversial backlash, as people reacted so negatively to the photos that she was actually forced to defend her decision for posting the photos in the first place. Which honestly is just a very sad state of affairs. Also, the BBC article linked above doesn’t provide 100% accurate information. UK guidelines for breastfeeding are in line with WHO guidelines, and state that babies should be breastfed exclusively for six months and then continue to be breastfeed for a minimum of 2 years OR BEYOND, in addition to the food they’re eating. For the record, the right time to wean is whatever feels right for mom and baby, but the biological norm for our mammalian species is to breastfeed for anywhere from 2-3+ years, and as with all phases of growth or development, there’s a huge range of normal in terms of the right time to wean depending on the mother and baby dyad. It’s irresponsible to suggest that the UK guideline only encourages breastfeeding for the first 6 months. As for the controversy, unfortunately that’s nothing new. People are often outraged by the thought of breasts being used for purposes *other* than sexual, and sadly we hear of stories all the time of women being shamed for nursing in public, or told to use the toilet instead. And not surprisingly, most likely due in part to these cultural perceptions, the UK has one of the worst rates of extended breastfeeding of any developed nation in the world–even lower the the US’ rate of extended breastfeeding, which is quite surprising given that women in the UK routinely have 6 months of maternity leave (and often a year) compared to women in the US who often receive a scanty 6 weeks, if they’re lucky enough to receive anything at all. Clearly there’s still A LOT of room for improvement, and personally, as someone who’s still nursing her own two year old, I applaud Tamara Ecclestone’s decision to share her beautiful photos, which is an important part of how we can begin to normalize breastfeeding in the first place. The Milk Meg also has a wonderful article on this entitled: 9 Reasons my child is not “too old” to breastfeed.

And finally, this is a fascinating article by Kathleen Kendall-Tackett, IBCIC (who I saw at the LCGB conference last year, and is a fantastic speaker), discussing all of the ways that breastfeeding doesn’t just provide the optimal food for our babies, but also provides the best emotional and neurological foundation for their mental health. Breastfeeding encourages responsive parenting, promotes sleep (which in turn supports better parenting, as well as lowering the risk of postnatal depression–and breastfeeding is an independent factor for reducing maternal depression as well, regardless of sleep). Breastfeeding also promotes nurturance, attachment and bonding. As I often tell clients, breastfeeding is 10% about the FOOD we’re feeding our babies (and what incredible food it is!) and 90% about THE MANNER in which we’re feeding our babies, setting them up for healthy brain growth, emotional processing and psychological attachment in addition to optimal nutrition.

It’s ALL Happening: Midwifery Seminar, Timetables, Bursary Approved!

It’s ALL Happening: Midwifery Seminar, Timetables, Bursary Approved!

It’s all starting to get very, very real! I went to my new university on Friday to attend a midwifery seminar, which they hold every 6 months or so. It was a fantastic morning listening to some very interesting speakers and topics (I’ll give you a run-down below). I also received my student timetable for the first year of the course (let’s just say….lots and lots of work ahead, and very few holidays), and yesterday I also got a notice from the NHS that my fees-only bursary has been approved. What a huge relief that is! And for the record, I am an incredibly lucky student, as I am part of THE VERY LAST COHORT of incoming midwifery students who will be eligible to receive an NHS bursary. Starting in Aug. 2017, all incoming midwifery and nursing students will have to pay for their education (to the tune of 9,000 GBP per term), whereas if you are lucky enough to begin your education under the old scheme (as I am), your fees will be covered for your entire course (i.e. 3 years worth of education). As you can imagine, there are a lot of organizations (most notably, the RCM and RCN) which were quite distressed about this change, as it may limit the numbers of incoming student nurses and midwives and destabilize the future of maternity care in the UK. I am not entirely convinced about this, as midwifery and nursing education has ALWAYS been paid for by students in the US, without detrimental effects on the number of students choosing to enter these professions (but obviously coming out with lots and lots of student debt at the end of their education, which isn’t necessarily a good thing at all). In any case, though, as an American student approaching midwifery education here in the UK, I must admit that I am absolutely floored (flabbergasted! Amazed! Delighted!) that my education will be covered by the NHS, as I would never in a million years dream of free tuition in the States for any degree. It feels completely surreal to me, especially as I spent years and years paying off my student debt from my US midwifery and nursing education. And I am counting my lucky stars that I am slipping in just under the wire and will have my fees covered, but at the same time saddened that this incredible system–a system that values a student’s time and energy, and understands that properly educated professionals require investment–is being dismantled.

I met a few of the students who will be in my course, though, as well as a few of the professors, and everyone was incredibly kind and welcoming. I even met a third year student who gave me her phone number (unprompted by me!) and told me that I could get in touch with her at any point if I needed help. What a kind thing to do, and such a wonderful example of mentoring.  All of it seems very encouraging, and is making me think (again!) that I’ve chosen the right university to study at. The atmosphere was warm, the students were engaged, and the questions being asked were perceptive, smart and on-point. I am very excited about learning here!

The first speaker at the seminar was the one and only Professor Cathy Warwick, CEO of the Royal College of Midwives (and how fantastic that she’s speaking at conferences at my university??). Her presentation was on the importance of challenging the status quo in order to better deliver personalised care to each woman, which is a core value reflected in the National Maternity Review’s Better Births policy, but is not always easy to implement when a woman’s desires for her birth clashes with the institutionalised norm. She discussed many of the common situations where care is provided based on ritual (i.e. we do it this way because we’ve always done it this way), rather than evidence of best practice (examples of these sorts of non-evidence based rituals include transferring women between wards in a wheelchair when they’re perfectly capable of walking, not allowing fathers to stay overnight in early labour, routine use of external fetal monitoring on admission, transferring women from birth settings in an ambulance regardless of the reasons for the transfer etc. etc.) Prof Warwick pointed out that delivering personalised care presents big challenges for midwives on a systemic level, but that in many situations massive system changes aren’t needed. She spoke, for example, about how you can begin as simply as removing the word “allowed” from your vocabulary (something I can 100% get behind). The woman in labour is the one in charge of her birth. As midwives, it’s our job to support and empower her, but ultimately she should be the one making decisions (in collaboration with her midwife and birthing team). Telling a woman she isn’t “allowed” to do something goes against this sentiment. Ideally, a woman should be able to do whatever she likes in labour and on the ward (within reason), so long as the risks and benefits of her choices have been fully explained to her and she has been given the opportunity to make an informed decision. It’s HER birth, after all. Prof Warwick also pointed out that in some cases, women are labeled as “birthing outside of guidelines” as if they are stubborn and intractable and taking unnecessary risks with their babies, when in fact they are successfully advocating and demanding the type of birth experience they want and are legally entitled to. A better question is: how do we support women who challenge birth conventions/ norms of institutions, and choose to birth outside of these norms? As a strong advocate for home birth, this is something I have encountered many times before, and something that independent midwives facilitate, as many women who choose independent midwifery care are doing so because the institutionalised care offered to them was not in sync with what they desired for their birth. (And I must admit, I found it incredibly encouraging to be hearing this from the CEO of the RCM, especially in light of the recent difficulties imposed on Independent Midwives by the NMC). Safety and risk is perceived differently by every woman, after all; what feels safe to one woman could feel like the definition of risk to another. Prof Warwick also spoke about the need for not only continuity of care, but continuity of carer, and was quite adamant that figuring out how to deliver this type of continuity is something that can only be done by midwives (and that most likely the way forward will be different for each individual midwife, in terms of case-loading v. shift work v. shared call), and that midwives need to be given the power and flexibility to find their own solutions.

The next speaker was Margaret Nyudzewira, a public health advocate and co-founder of the charity CAME Women and Girls Development Organisation (CAWOGIDO), who spoke to us about breast ironing. While I’ve been aware of the dangers of Female Genital Cutting (FGC, or Female Genital Mutilation, FGM) for years, and have encountered it a few times as a midwife in Brooklyn, the practice of breast ironing is fairly new to me. Strangely enough, I first learned about it just a few weeks ago when a midwife friend posted a link to a photographer’s riveting portraits of women and girls who’ve experienced breast ironing.  The practice involves using a tight elastic band, pestle, ladle, hot stone, shell, or even hot seeds or heated leaves, to massage and flatten developing breast tissue on young girls, and can lead to many serious medical complications, including chronic pain, scalding, burns, infections, cysts, abscesses, tissue damage, the inability to breastfeed, and of course psychological trauma. Breast ironing is most often done by the girl’s mother (but can also be done by a grandmother, aunt, or tribal practitioner), and comes from a place of love, or more specifically, fear for loved ones–fear of unwanted sexual attention directed towards their daughters, fear of rape or sexual assault, or fear that early marriage or teen pregnancy could education and curtail opportunities.  And similar to FGC, this practice doesn’t occur only in Central and West Africa, but in the UK (and the US) as well (although the numbers are difficult to track, and very few studies have been done on the rates of breast ironing in the UK). In Cameroon, 50% of girls on the coast, and 24% of girls nationwide, experience breast ironing.

But one of the things that struck me the most was when Ms. Nyuydzewira said quite emphatically: “It is NOT part of our [Cameroonian] culture to harm girls and young women.” And that is absolutely true. While the practice of breast ironing itself is brutal and debilitating, it’s really important to keep in mind that the practice and the culture are not exactly one and the same. As a (white) midwife approaching a cultural practice like this (which runs counter to my own beliefs, and feels very foreign to my own cultural upbringing), I think it’s crucial to come from a place of support rather than a place of judgement.  This is one of the reasons I have come to call it Female Genital Cutting over the years, rather than Female Genital Mutilation (which has our cultural judgement baked into the very name itself) or Female Genital Circumcision (which to me seems to condone the practice, on some level, and also equates it in the mind with male circumcision, which is a false equivalence), especially when I’m discussing it with women/ patients directly (I understand that more generally, in health policy and research, it is more often referred to as FGM). Some women brought up in cultures which practice female genital cutting, for example, may view FGC as no more strange to them than piercing bellybuttons or lips or eyebrows is to us, even if the implications, the actual act itself and the repercussions of it can be much more damaging to them than a bellybutton piercing.  When viewed within their culture, it may be seen as a mark of belonging and identity, a much anticipated rite of passage, a way of fitting in, a symbol of their womanhood, a manifestation of their virtue and honor, and on its most basic level, the way that vaginas are supposed to look–beautiful, even, to their eyes. On a personal level, I disagree with these assertions and find FGC abhorrent, but as an outsider to these cultures, I can’t approach a woman by telling her that she’s been mutilated as the starting point for any future conversations with her–that will immediately close her off to me and only serves to project my own cultural bias over her own.  Instead, gentleness and sensitivity is needed more than anything else. Rather than imposing my own viewpoint, I would have to elicit the woman’s own views on the topic first, and use that as the starting point for whatever would be most useful to her moving forward: education and resources if desired, medical care if needed, mental health referrals if she feels depressed or traumatised by her experience, or silence and non-judgement if she views it in a positive or neutral light (and should this viewpoint ever change, I can then step in at that point with whatever help or support is most appropriate at that time).  To me, this gets to the very heart of my own personal philosophy of midwifery care: LISTEN to women, and DON’T JUDGE. In any case, now that breast ironing is also on my radar, I will be more alert to it if/ when I ever encounter it, and in a much better place to offer sensitive care on this very complex issue. Overall, it was a difficult and disturbing presentation to listen to, but I’m glad that it was part of the seminar, as these things are really important to think about in advance of encountering them!

There were two other speakers at the seminar: Debra Sloam, Midwife and Infant Feeding Specialist from Frimley NHS Foundation Trust, who spoke about her MSc research on student midwives’ attitudes towards offering breastfeeding assistance (as suspected, I will most likely have a lot more time to help women breastfeed as a student than I will as a working midwife), and Dr. Kim Russell from the University of Nottingham, who discussed her action research on challenging midwifery barriers (real and perceived) to facilitating water births on the wards.  These were both interesting and engaging presentations, and I’m really glad I was able to attend the seminar.

Two more weeks until classes start!

 

My First Week Away From Them

My First Week Away From Them

I just spent a week away from my boys–the longest time I’ve ever been away from them since my eldest son was born five years ago. I went skiing with some good friends, entirely on my own, while my partner held down the fort in my absence.

I think I’ve been dreaming about this week away for nearly five years now. In the early, bleary-eyed days of new motherhood, when I was certain the exhaustion would kill me, I dreamed about mere hours away.  A week was unimaginable, but I would fantasize about someone taking my son and holding him for three hours while I took a nap. And in all fairness, there are several occasions when I can remember exactly that happening. My in-laws would babysit every now and then, or my partner. Once two work colleagues took him for a walk for two hours while I slept on the couch, and once, in desperation, I went to a friend’s house 10 blocks away and slept in her bed for three hours, as I found it nearly impossible to sleep–really sleep, deep and undisturbed–if the baby was anywhere in the house with me. Even his slightest whimpers, faint snufflings in his sleep, would set me bolt upright, in those early days, so any chance of a real nap would have to be done away from him.

And then, as he grew older, I began to dream about entire days away, and even entire weekends. I would imagine how glorious it would be, how unfathomably luxurious, to have an entire day to myself. To do the things I used to do, the things I took for granted, before I had children. To sleep in late, have a lazy morning in bed reading the paper, showering for a full, uninterrupted 20 minutes, enjoying a leisurely brunch at a local restaurant, lingering over my coffee–hell, on some days even an uninterrupted 5 minutes on the toilet felt luxurious, the stuff of fantasies.  I couldn’t imagine an afternoon spent browsing through bookstores or watching a movie, cooking a complicated meal from a new recipe book, knitting while watching TV, drifting off to bed whenever I felt tired, rather than trying to sprint through the evening’s interminable to-do list with the bed at the finish line and the distance between us growing longer and longer.

My partner would leave, often for work but sometimes for pleasure, and I would think about how much easier it was for him to have a week or weekend away. He was less tethered, his life carrying on in many of the same ways that it had before children, whereas for me my post-kids life was unrecognizable to my pre-kids life. I was often unrecognizable to myself.  Some days I would cry bitter, jealous tears about this. Some days I felt like I was the default option, taken for granted. He could head off on stag-dos and weekends away because I was at home, maintaining the routine, ensuring that naps were had and noses were wiped, food was cooked and cleaned up and cooked and cleaned up again, bodies bathed, teeth brushed and bedtimes kept. Needs were met. That was partly where the bitterness came from; that needs came before wants for me now, and that there was never time or room or energy for my wants, whereas my partner could still occasionally fulfill some of his wants.

But little by little, I started to have opportunities to leave. First an evening out with girlfriends after putting the boys to bed, so that they never even knew I was gone, and then an afternoon here, a morning there. A day spent at a conference now and then. I started working again, one day a week as an IBCLC at a breastfeeding drop-in (strangely enough, my day spent “working” often felt like a holiday), and then I began working two days a week, and then three. An avid runner, I began to train for another marathon about a year after my second son was born. I spent hours away, running. And then, for the race itself, I left for an entire weekend away with my partner, while the grandparents watched our children. Brief glimpses of my former self, snatched here and there like an exhausted swimmer coming up for air.

But now, for the first time, with a five year old and a two year old, I am finally in a place where I can go for a week and not feel like my absence will be harmful to them. In fact, I feel quite the opposite–that it would be good for all of us.  Good for me to be away, good for them to realize that they can manage without me (for a little while, at least), good for my partner to be on his own, and understand what it feels like to be the one left behind, holding down the fort, and good for them to see their daddy not just helping me, but single-handedly doing all of the tasks I normally do.  Good to change the routine and remind ourselves that we’re all flexible, that we can adapt. And for the record, my partner is an incredibly capable and involved dad. Leaving him alone with the kids for a week is by no means beyond him, or even a stretch for him, and I had absolutely no qualms about it. They’re in good hands.

And so, here I am, on my own for a week…and it’s been WONDERFUL! But it’s also felt like I’ve had an arm chopped off. I keep feeling the phantom twinges of my family all around me, as if I’ve lost something really important and keep forgetting what it is. I walk into restaurants and start to ask for a high chair before remembering that it’s not needed.  During dinner, I keep feeling like I should be doing a gazillion different things besides just eating my meal and enjoying the conversation. I should be reminding the older one to use his cutlery, reminding the younger one to sit still or he’ll spill his water, trying to get both of them to have a few more bites or else there won’t be any pudding, snapping at both of them to stop harassing each other, refilling plates and making pointed reminders about using napkins, cutting meat and retrieving forks off of the floor etc. etc. It’s as if I’ve gotten used to juggling eight balls while also eating a meal, and now all of a sudden the balls have disappeared…but I still feel like I should be juggling.

And how strange it’s been to move through the world unencumbered again!  To only have to think about myself and my own needs. To be the one traveling light, to sail through airport security in a matter of minutes. To board a plane on my own, with a good book to read and no mental checklists involving emergency snacks and drinks, knowing exactly where various toys, books, games and Lovies have been stowed, checking the batteries on the iPad which is the inevitable emergency back-up to the games and books, and making sure that nappies have been changed and wees had before boarding. To just get on a plane, sit down, put on my seatbelt and be ready to go. How unbelievably decadent! I can roll out of bed and be ready to go 20 minutes later, whereas usually dressing, cleaning, feeding and preparing my children to leave the house is a 1.5 hour long endeavor. The freedom and ease is staggering!

Our culture is really good about focusing on the positives of motherhood and glossing over the negatives, but in truth, motherhood is usually always a mix, and it’s important to acknowledge the dark as much as the light. So much love you feel like you’ll burst (!!), on a daily basis, but also so much uncertainty, responsibility, tedium, loneliness and isolation (and in many cases, depression and anxiety as well). Lots of dark in addition to the light, and rarely a perfect balance of the two. And in those first few days and months, nothing can prepare you for how swift the bulldozing of your identity and former life can be! I feel like the process of becoming a mother razes your identity to the ground, and then, in the wreckage of your former life, you slowly begin to rebuild your identity from the ground up, trying to figure out how to reincorporate all the pieces of who you used to be into this new shape.  And bit by bit, over time, you remember the things you used to enjoy and do on your own before motherhood, and learn new ways to do them again. But this week has made it very clear to me that you never go back to being the person you were before you had kids, even when you do get to the point that you can leave them for a week. All of those months and years fantasizing about time away, so that I could be who I used to be, even for just a little while, is impossible.  That person is gone. Those things I used to love to do before children, I still enjoy, but now they don’t feel like they’re quite enough for me, on their own, because I guess it takes more to fill me up now.

And I miss my kids like crazy. This time away has been nourishing and vital, and very eye-opening, but I feel like what it’s done more than anything else is give me energy to plunge back into the fray of parenting again. And be a better mother for it, as well. I can’t wait to see them again!

NMC threatens Independent Midwifery again

NMC threatens Independent Midwifery again

Back in 2013, Independent Midwives (IMs) in the UK were facing a crisis: a new EU regulation was coming into effect in October of that year which would require all IMs to carry malpractice insurance (and would therefore make it illegal for IMs to practice without indemnity insurance). At the time, it was difficult to find an insurer willing to cover IMs, and given that the pool of IMs sharing the costs of insurance was small, the quotes from insurance companies at the time were prohibitively expensive. Thankfully, after several petitions, protests outside of parliament, and a long and drawn out campaign by IMUK, a resolution was found in early 2014 that enabled self-employed IMs to purchase insurance through a pooled indemnity scheme set up by IMUK itself rather than using a third-party insurance company, which allowed IMs to continue to practice legally.

However, this past Friday (the 13th, no less!), the Nurse and Midwifery Council (NMC) made a decision that the IMUK indemnity scheme does not provide adequate coverage (i.e. sufficient funds), particularly if a serious case of malpractice was ever brought against an independent midwife using the scheme. From the NMC’s statement on their website:

The NMC’s investigation found that the indemnity scheme provided for IMUK members was not able to call upon sufficient financial resources to meet the costs of a successful claim for damages for a range of situations. These include the rare cases of catastrophic injury, such as cerebral palsy. This could have the effect that mothers and babies who suffer injury through the negligence of an attending midwife are not properly compensated for their injury. (NMC, 2017)

Which basically means, that as of Friday 13th, 2017, any independent midwife using the IMUK scheme is now considered to be practicing illegally, unless they can find a different indemnity insurer to cover them ASAP.

As you can imagine, this has created quite a bit of chaos. Women who chose independent midwives for their care and have developed trusting relationships with them throughout their pregnancies are now being told that their chosen midwife can’t attend their births, and that they’ll have to find alternative arrangements, in some cases with only days to go until their due date. Even more cruelly, the NMC has specified (on Page 2 of their guidance) that IMs using the IMUK indemnity scheme will not be allowed to attend their clients’ births in any capacity, even in a non-midwifery role, which is particularly harsh given that the general standard of care during home to hospital transfers is for the IM to remain with the client in a doula/ emotional support role even as the midwifery role is transferred to NHS midwives.

In an urgent letter written to the NMC on Friday the 13th, Rebecca Schiller, CEO of Birthrights (the human rights in childbirth charity) expressed her dismay over the NMC’s decision, criticising many of the  implications of this decision:

While we are aware that some women may be able to transfer to local NHS home birth services, we are concerned about the safety implications of this. Local NHS home birth teams will not have antenatal records relating to women who book later in pregnancy and there will be a very limited opportunity for a named midwife to build a relationship. In some areas there are limited, unreliable or no home birth services at all, which may have prompted the woman to use the services of an independent midwife. Furthermore, many NHS home birth services are unwilling to support women who are making an informed choice to birth at home outside of guidelines. In these cases we believe that women will be unable to give birth at home with appropriate clinical care.

As the regulator for the midwifery profession in the UK, it’s certainly important that the NMC sets and enforces clear safety guidelines. However, the amount of indemnity coverage a midwife has does very little to ensure safety. All it ensures is that in the event of a tragedy, the affected family will be able to sue the IM who did the delivery for a larger amount than they otherwise would be able to.  As Richard Chappell at Philosophy.net succinctly summarised in his article about the decision:

NMC Chief Executive and Registrar Jackie Smith has responded with the claim that “The NMC absolutely supports a woman’s right to choose how she gives birth and who she has to support her through that birth. But we also have a responsibility to make sure that all women and their babies are provided with a sufficient level of protection should anything go wrong.”

In other words: nice as a women’s right to choose might be, what’s really important is that she can sue for many bucketloads of money (not just a few bucketloads) if anything goes wrong.

BirthRights has also questioned the timing and manner in which this decision has occurred, as it’s left many women who had booked independent midwifery care without a clear way forward.  The NMC has been particularly opaque about what amount of coverage would meet their safety standards, despite both IMUK and Birth Rights asking for clarification. For example, in the NMC’s own policy guidance on indemnity insurance, they state:

We are unable to advise you about the level of cover that you need. We consider that you are in the best position to determine, with your indemnity provider, what level of cover is appropriate for your practice. You should seek advice as appropriate from your professional body, trade union or insurer to inform your decision. You need to be able to demonstrate that you fully disclosed your scope of practice and to justify your decisions if asked to do so. (NMC, 2017, Page 3)

Therefore, they are raising an objection to the amount of coverage IMUK decided upon, while simultaneously stating that the amount of coverage can be determined by professional body, insurer or trade union (i.e. IMUK)–not exactly helpful in terms of figuring out what amount of coverage would satisfy requirements.

The NMC’s press release also implies that the NMC has been in talks with IMUK about the inadequacy of their indemnity cover since 2014 and that if their clients now feel suddenly surprised by this decision, it’s the fault of the IMs for not updating them about this issue. However, the final decision was only reached 3 days before Christmas, which left IMs and their pregnant clients scrambling for alternative care arrangements over the holiday season.  Additionally, in the NMC’s press release on their decision, they go out of their way to stress that this only affects a small percentage of midwives in the UK (approximately 80 out of 41,000 midwives), as if that makes it ok.  But this small number includes nearly every independent midwife working in the UK, and the women the IMs are caring for are as equally entitled to their chosen provider and manner of birth as any of the other women cared for by the 41,000 other midwives in the UK. As Milli Hill wrote in the Telegraph back in 2013 when the insurance coverage was first threatening independent midwifery as a profession:

If … Independent Midwifery becomes illegal, this will be a grave blow to birth freedom in the UK. The NHS will be left unchallenged, a monopoly, and a system that already seems to be over-stretched and flawed will be left to continue without an alternative for anyone to compare it to. Women who seek an different option to the mainstream will have no choice but to birth unattended, or perhaps in secret with an midwife practicing illegally. Will this really improve birth safety?

Independent Midwifery provides the gold standard of midwifery practice in the UK: trusting relationships, continuity of care, respectful, informed choice, and freedom to birth where and how the woman would like, and is therefore something that needs to be protected, even if the number of women choosing this type of care is ultimately small.

As it stands right now, talks are ongoing between IMUK and the NMC, and IMUK has filed a legal challenge to the decision, while IMs are seeking out alternative indemnity cover. The RMC has also proposed that honorary NHS contracts could be a solution for IMs in the short term.  If you get a chance, please sign this petition in support of IMUK. This post also explains more of the history of independent midwifery and the insurance issue that has come up since 2013, and of course, you can continue to follow IMUK and Birth Rights for further updates. Hopefully a resolution will be found soon!