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Thoughts on power in antenatal education.
In reading Rachel Reed’s book Reclaiming Childbirth as a Rite of Passage, this sentence jumped out at me: ‘Women are groomed to rely on external assessments of their own and their baby’s wellbeing and on the experts who know how to use the technology’.1 ‘ Groomed’ is a strong word with connotations of a scheming predator and innocent victim, and its use created a strong emotional reaction in me.
Rachel also cites research which concluded that antenatal education provided by hospitals provides an opportunity to groom women to comply with hospital policies and cultural norms. Even attending appointments in a medical setting may start to shape a person’s relationship to pregnancy, what’s considered normal, and their sense of being able to trust their internal sense of baby’s well-being.
The parameters constantly change around physiological birth and when it becomes too risky. The recent publication of the NICE’s draft ‘Induction of Labour’ guidance proposes inducing labour in normal pregnancies at 41 instead of 42 weeks.* It feels that maternity services are ever reducing the chance for physiological birth to unfold within a culture of risk.
Across pregnancy forums there are posts about routinely being induced at 39 weeks for a big baby or maternal age. This seems at odds with the woman-centred (and centring of other birthing people) and individualised care plans on maternity services webpages. Examples like these explain why Rachel used such a strong word as grooming.
What about antenatal education?
Many of my yoga clients share that they feel more anxious after free hospital or paid-for antenatal classes because the focus is on providing information about intervention rather than on practicing techniques that they can use as a gentle way of managing baby’s positioning or the intensity of contractions. As I reflected though, I saw that these “natural techniques and practices” are still an external intervention that took women away from their own instinctive strategies. So how best to enable someone’s trust in their instinctive knowing and support their journey from that place rather than fear?
The fundamental issue is that the birthing culture has been removed from everyday life. For most in the Western world, it has been taken out of the home and into a medicalised setting. On TV and in film, we usually see a woman on a hospital bed, being told by others what to do and sometimes people actively pushing their legs back or apart. I am a champion for physiological birth, a proponent for as-undisturbed-as-possible birth. My justification for this is that I’m providing balance: sharing information and practices that open up the choices for expectant parents in the way they want to approach birth when we medicalised birth has become normal.
Rachel’s statement that ‘Antenatal education provided outside the hospital system is also capable of grooming compliance, albeit with alternative cultural norms’ is also true.* Could it be that as pregnancy yoga teachers and birth preparation educators that we may unintentionally create an alternative cultural norm for those in my classes around normal or physiological birth?
The danger of expertise
Any pregnancy, birth or postpartum professional may come across as an expert to expectant parents because they are sharing knowledge or experience acquired over many years. In mainstream maternity services, the obstetrician is seen as the apex expert. Expertise is undeniably useful. However, it is abused if compliance is achieved through reinforcing the power and authority of the external expert over the knowing and wishes of the pregnant woman. Any clinician or educator is at risk of doing this.
Feeling safe trumps everything else
Another book that has been influencing my inquiry is the Call of the Wild. Kimberly says, ‘When we feel safe in our social nervous system, we know that we can be ourselves, have needs, express our uniqueness, and still belong to our family or our community’.** This includes knowing that the care in labour for yourself and your baby won’t be affected if you do not agree with the caregiver. For example, if you do not want to be induced or want to wait a few more days. Or that if you went to a workshop about using biomechanics in birth (to support baby’s movement through the pelvis and protect the perineum) that you don’t feel excluded if your baby arrives via a caesarean birth.
The sense of belonging is a fundamental need for human beings. When our belonging is threatened, or danger is detected subconsciously or otherwise, we may try fitting in or fawning before we resort to flight or fight.** Fawning is where you become nicer and less threatening in a subconscious way to de-escalate the perceived danger. For example, if you overheard a negative comment during labour about yourself, like ‘I have a difficult one [patient] here’, you might make your requests milder or simply stop expressing your needs.
What happens when you give up your agency?
The relinquishing of or dismissal of agency is often what leads to a negative birth experience or birth trauma in my experience of working with people who are living with these. Kindness, compassion and empathy are essential when someone feels their safety and belonging are threatened, which is harder to consistently provide when there are staff shortages or protocols to be followed under time pressures. At the extreme, someone may seem to be going along with proposed intervention, but actually be in a state of freeze because their body has shut down because their perception of danger is so great. Being trauma-informed is important for those gaining informed consent.
What can we do as educators? What should you look for in a course?
I can share what I have learnt during this inquiry. First, if I was trying to convince someone, it would be an attempt at exercising external power. My aim has always been to share information, enabling decision-making and agency within a system of unequal power, and suggest practices to expectant parents to try for themselves and check the fit for them. What I need to be better at is making it clear that my intention to share what supports physiological birth is to balance the increasing medicalisation of birth, but that I have no judgement or preference about how birth happens for the individual.
This is why in the closed Facebook group for my classes, I share all the birth stories that are sent to me (with the parents’ permission). I heard someone say that she did not sign up for a well-known online birth preparation course because they would only post the ‘positive’ stories. This sets up parents for feelings of failure when they see only one birth outcome (the unmedicated, non-intervention one) presented as the norm in a group.
Second, what I notice is that it would be easier to fall into grooming and convincing when time is tight. When there is time and space to sit with someone and listen to what they’re experiencing in their bodies as they think about pregnancy and birth, they often find their own sense of what is right from a position of authentic knowing and power. This is what I tried to encourage through the Reflections sections of my book Pearls of Birth Wisdom; an inner journey to sensing what feels right internally and within the environment you find yourself.
Third, I put the mother in the forefront of the stories I share. I made a decision to ask for photos for the birthing stories that have the mum as well as the baby pictured. How often is the baby pictured alone, or against the mother’s chest with her head out of picture, or midwives holding babies with no mum in sight on International Day of the midwife? This may seem a little thing, but think about the message we perpetuate when the person who gave birth is not pictured. An athlete or warrior would be pictured celebrating, with the sweat and exhaustion on their faces, so why not the mothers?
Fourth, my intention is to keep supporting mothers-to-be in my classes to develop their own experience in what safety feels like in their body, to know what choice and agency feel like, and to listen to their felt-sense for what feels disconnected, unstable, based in fear, and what is aligned, grounded and based in love. This takes frequent practice beyond a class situation.
What can you do if you’re pregnant and reading this?
Ask questions about everything. The vaginal examination that you thought was compulsory? Question it. Some good places to get balanced information is from research midwives Sara Wickham and Rachel Reed. Get an advocate who can support you in making choices and being heard, like a doula or birth keeper like Kemi Johnson. There are support funds to access a doula. I would put my money on an advocate rather than brand new nursery furniture or travel system.
There is a tension between what you believe in, will stand up for, and holding space for others to travel a path that may lead them in a different direction. It’s a tension that I keep practicing holding. I aim to lay my knowledge at their feet and tell them explicitly that they will always be welcome, always belong, whatever choices they make. I feel that many birth educators think this is implicitly understood by parents, but it’s too important to not say aloud.
Tessa Venuti Sanderson teaches Birth Preparation Workshop trainings for yoga teachers (tessayoga.co.uk) and is organising The State of Birth online symposium, November 2021 (http://www.thestateofbirth.com). Tag her on IG @birth_wisdom_pearls to share your response to this article. Watch pregnancy videos at YouTube.com/user/tessa.venuti
*NICE is the National Institute for Clinical and Health Excellence.
** Kimberly Ann Johnson 2021 Call of the Wild. HarperCollins.
Or sensitive being?
When a baby appears needier than others, it may be that they are a ‘highly sensitive person’ (HSP), which can have many benefits in later life. It can mean that as a parent your role is to protect your little one from being easily overstimulated and as they grow older help them to explore new situations from a place of safety.
Living with highly sensitive babies can feel exhausting and make you wonder if you did something wrong, so this article explores some ways to do this and hopefully gives a sense that your instinctive way to react is exactly right. Most of all you need to know you are not alone.
Stitches, incontinence & other issues
In pregnancy classes, I talk about how to help prevent tears in the perineum (and deeper) through perineal massage, positioning, squats to keep the perineal tissue elastic, asking the midwife for a warm compress as your baby's head emerges and more.
However, sometimes despite everyone's best efforts a mum will sustain a tear (of different magnitudes). In this short blog, I list the suggestions I received for a mum struggling with healing an episiotomy from a specialist antenatal and postnatal group of professionals that I belong to. However, many of the suggestions will also be useful for those who healed from a minor tear and some also for those with a caesarean scar.
The suggestions are in no particular order. I suggest you read through and see what you are most drawn to as the list is quite long and could feel overwhelming for a new mum struggling with physical challenges. I have given suggestions for specialists local to Reading, Berkshire, if you are elsewhere please ask your peers for recommendations.
- Lots of suggestions for healing herbs. I recommend Sarah Smith (https://www.facebook.com/redearthholistic)
- Push for a referral to an obstetric physiotherapist or recommended postnatal physio or chiropractor (e.g. Kelly at Dynamic Family Chiropractic)
- Get a valley cushion (e.g. through NCT - they hire them out) to make sitting more comfy
- This type of healing is very slow - months rather than weeks - take pain relief e.g. diclofenic / voltarol (PR) suppository can be prescribed
- Sitz bath in oat straw (Sarah above could help with where to source)
- Apply a compress with recommended Naturally Birthing Company's Pure Bliss Soothing Postnatal Compress Solution.
- Castor oil packs on the tummy (there is lots of advice online for these start with only a short amount of time)
- Yoni (womb) steam once stitches healed and lochia stopped - again Sarah call help with the right herbs to use to aid healing
- Once stitches have healed, massaging scar tissue (Sophie is trained to do myofascial release for the pelvic floor muscles and to release tension around episitomy scars, and to massage casearean scars http://www.berkshirepilatesclasses.co.uk/home-2/myofascial-release/)
- Once stitches have healed, visiting Holistic Pelvic Care practitioner (I recommend and have visited with Rachel - see http://www.thefeminineawakened.com/blog/archives/06-2017)
- For more complicated healing issues after episiotomy, or prolapse or incontinence, please contact me for signposting to a well recommended professional. Please don't put up with a situation that is getting you down or physically stopping you getting out the house.
- Nourishing food - get family to prepare meals
- Lots of rest (I know this is difficult with a small baby, but stay in your nest as long as possible getting friends to come to you when you need to see a friendly face).
- Go through notes with consultant midwife or independent midwife if it was a challenging birth and you need to understand why you are in the situation you are in (e.g. Kathryn Weymouth)
- If incontinence, proplapse or diastasis (tummy gap) are an issue, contact me, Tessa, to learn Hypopressive exercises.
Hopefully there are some suggestions there for whatever level of healing is required. PLEASE do not put up with something if it is not feeling right, just because it is 'down there'.
Incontinence, prolapse, excess scar tissue etc are common but not normal so please seek help.