connecting midwives

so running through facebook, it occurred to me that I know a lot of (mostly) women in the birth sector, most are midwives or doulas, the rest activists.

What came to me is that there is no real forum for all to unite.

MANA is arguably that medium, but its too political. It has an agenda. In the UK they have ARM - Associated of Radical Midwives. These midwives are not some patch wearing activists that are storming the streets demanding what they want. They are average midwives, trained with in the British midwifery system and have fallen to being on a spectrum between obstetric nurse to independent midwife. The name itself denotes political power, but really the organization is about change, and the acronym (truncated from AROM - or artificial rupture of membranes) was something all too familiar to them.

In Canada and the United States, I don't see much unity. We have the Big Push for Midwives Campaign, but that focuses on certified professional midwives and is consumer led. Then we have ACNM (American College of Nurse Midwives) who have gained control of the URL "midwife.org". MANA - Midwives Association of North America represents all, but I don't think anyone could deny the direct-entry focus of their cause, trying to make midwifery a legitimate profession.

What I see from these organisations is a struggle from within to give self worth. The focus is on the group itself, rather than on the care of pregnant mothers.

Perhaps I am coming late to the game and dishonouring all of the work that has been achieved to this point that I can even be sitting here, an apprentice, a student, judging the system within which we live.


Maybe it's my own dissatisfaction within my self for not doing more to promote midwifery, but not just midwifery, access to it, the organisation and distribution of services, insurance coverage, prevelance, supply/demand, the list goes on.


I'm about to start a project that will exam choice of birth place. My null hypothesis is a despotic one, that birth is a white middle class issue.

This is not to say that there are problems with maternity care across all socio-economic or ethnic groups, but that for what ever reason, it is white middle class women that are leading the movement away from hospital birth.

Questions that arise include:
1. access to information
2. access to services
3. financial limitations
4. insurance limitations
5. cultural tradition

These are but a few factors that may influence a woman's choice of birth place.

Over the next while I will conduct a review of the literature that has been published on the subject. My plan is to analyze MANAstat information to find trends in the utilization of midwives. I would like to incorporate a maternity care survey to help further glean insight into this question.

Today midwives are returning as holders of community knowledge. Protectors of all that is natural and healing on the earth. But is this really true of all midwives? Do lay midwives, CPM, LM CM CNM all have access to the same knowledge?
Do we all practice under the same system of beliefs?

Returning the point I raised at the onset of this, what are midwives doing to join forces to help extend access to their services to a broader population?

First we need to recognize that as midwives today, the large majority of us are white, and most likely fall into middle class. Once we accept this disparity on the behalf of the caregiver, we may begin to understand the disparity in care being provided and received by consumers.


This is just a intro to the topic. One I will continue to address in the coming months as this project unfolds.

Comments, suggestions, thoughts and beliefs are welcome.

Birth in Rural Saskatchewan: a picture of three women in one family

Discovering the history of birth in my family was no easy task. On my mother’s side, some topics are better left alone until they can properly be approached. On my fathers side I found that birth was simply not a topic shared between the women. I spoke with two of my eldest aunts, hoping they could enlighten me about their births or that they may remember something about the birth of their siblings. The following account represents the birth stories of three women in my family. I believe a comparison between their births is important to understanding how birth was perceived in rural Canada, how it changed over time and how it fits into the overall context of birth in Canada.

My baba (grandmother) had eight children born between 1939 and 1952. I knew previously that several of the children were born at home, while the younger children were born in the hospital. My eldest aunt (Evelyn) gave birth to her first child in 1958 and one of her younger sisters (Alice), also born at home in 1939, gave birth in the hospital during the 1960’s. I discovered a lot of information during this process, and connected with my aunts on a new level. It is interesting for me to examine all three women’s births relative to each other and how they were altered over time, yet in a way changed very little.

The information gleaned is slightly confusing. My aunts have little recollection of their personal birth stories and practically no memory of their siblings’ births. Granted, these are births that happened 50 to 60 or more years ago. I discovered first and foremost that birth was not a topic discussed with children and they had no involvement in the process, not even with the ones born at home. There seems to have been little agency, on behalf of the women in each of their births. I’m not sure about my baba, but clearly it did not give her a sense of empowerment, at least not one that she imbued her daughters with. Birth seems to have been more simply and fundamentally a biological act, rather than an expression of something more. 

Evelyn

Evelyn had been diagnosed with toxemia and spent the last week of March in the hospital before being released to celebrate the upcoming Easter holidays. My aunt and uncle made the long journey to visit some of their relative’s in Manitoba before returning to Saskatchewan. Upon their return, as a possible consequence of the traveling, my aunt began to spot. My baba told her to go to the hospital, where she remained until she gave birth to her first child at the age of 22, on April 15, 1958.

During her stay at the hospital, Evelyn shared a room with another expecting mother who was pregnant with twins, also diagnosed with toxemia. She recalls spending the day talking with this woman, but in the morning she awoke to find her gone. Later she was informed that the woman had passed away and only one twin survived. He still lives in their home-town of Canora today. This was the only moment of real fear my aunt experienced, as she herself had toxemia and did not know what to expect with her first child. When I asked my aunt if she was afraid to give birth she replied, “No, it was something you did. You just go through it, what else can you do?” Clearly, birth was normal and not something that she felt was an emergency, despite being diagnosed as toxemic and being admitted to the hospital.

I discovered neither of my aunts had any profound memories of actually giving birth after going into labour. Both recalled being given injections and then “went to sleep”, waking up later with their babies. Neither is sure what was given to them. With regards to the 1958 birth, Evelyn could only say “I must have fallen asleep”. It was painful to listen to her struggle to remember what occurred. I am not sure if her fuzzy memory is because it has been so long or because of the drugs she was given. She remembers going into labour, but nothing else, just “somehow going to sleep”. When I asked her if she actually remembers pushing out my cousin she responded, “Well, yes. Of course, I must.” However, I don’t know if this is true or if she is just filling in those gaps from her later births, or perhaps even said out of embarrassment for not having remembered.

Emergence of “Painless” Birth

Twilight sleep was first used regularly during childbirth in Germany by the end of the 1800’s (Cassidy 2006). It is an injection of morphine and scopolamine that induces a dream-like state, which is not remembered.  Scopolamine is an alkaloid drug derived from the nightshade family of plants, such as belladonna or jimson weed. In a 1958 article discussing the use and efficacy of a new sedative, promethazine, the author praises that “the relief of pain during childbirth has been one of the great achievements of medical science” (Hobbs and Carroll, 1958) and that the “latest preparations to be added to our armamentarium for pain relief during labour are the tranquillizing drugs”. This last statement reinforces the general view of the medical community was that ‘pain is something to be conquered’.  This seems to be consistent with the generally more paternalist medical obstetric system that was emerging, one in which women were viewed as helpless and needed to be saved.

Forty years earlier, in an article reprinted from the 1915 Canada Lancet (as cited in Michinson 2002) the view on twilight sleep was much different.  The author states, “the non-medical literature on it [twilight sleep] was one-sided and could not be trusted; scientific articles were more balanced, and their conclusion was that twilight sleep hindered labour and adversely affected the respiratory of the newborn”. Michinson (2002) continues, “many physicians dismissed it as a fad demanded by women ‘in the so-called higher circles of life’.  Clearly, not all physicians were keen on using the morphine-scopolamine combination, likely because it required that the labouring mother be closely monitored and therefore required much more effort on their part.

During the early twentieth century, twilight sleep had made its way to North America and into the hospitals. However, out west and in rural Canada it was a slightly different story than in more urban areas. It wasn’t until after World War II, that birthing at home became practically obsolete on the rural plains of Saskatchewan. Based on Evelyn’s account, the first notion that comes to mind is that the injection she received was to induce twilight sleep, a drug combination used, not to eradicate the pain, but rather the memory. One can just imagine from what we know of births that are recorded during this time; images of her being strapped down and losing control are too painful to even consider. I did not share my thoughts with my aunt, of what may have been given to her, and what that may have meant, but my heart sinks.

The actual birth of her first child does not seem to have had any profound effect on my aunt’s life. I’m curious how my questions may now alter her views and memories of the past. Perhaps this apparent lack of impact, 50 years later, reinforces the normality of the event. It wasn’t something that was necessarily sacred or life changing, but rather God’s intention for man and woman, procreation. Alternatively, the lack of impact could be a side-effect of literally having those memories unknowingly stolen from her.

Interestingly, Evelyn recalls positively the care she received in the hospital post-partum, but complains they taught her nothing. She believes the nurses gave the baby a bottle, likely sugar water, but she did breastfeed from the beginning. After staying a week in the hospital, being pampered and having everything done for her, when released she was lost. She had no idea how to care for her baby, not even knowing how to change a diaper (this is told to me from my other aunty Alice, who said that her older sister didn’t have a clue what to do, and came to stay with their mother for two weeks post-partum - something Evelyn had to be reminded of decades later).  This level of care is consistent with the perspective that maternity hospitals wanted to portray; they were a place for women to birth in a spa-like atmosphere, with no concerns in the world. With this type of care who wouldn’t want to birth in the hospital? Why would anyone want to birth at home? Just think of the mess that will be made, and the children will just be in the way.

Alice

My aunty Alice, who gave birth during the 1960’s in Regina, tells a quite similar story to Evelyn’s. She was given an injection and that was about all she recalls; nothing significant, nothing allegedly life altering. Again, it is almost painful for her to admit that she doesn’t have anything to really offer in terms of a “birth story”. Unfortunately, again my thoughts go to scopolamine and morphine and the fact that she was robbed of something so important. 

Baba (Anne)

I initially called my aunts to find out what they knew about my baba’s births. Reflecting now, they gave me much more information than I had expected. In addition to their births, I did glean some insights regarding my baba’s birth stories; she had eight children between 1936 and 1952.  My baba provides an interesting reference point, not only because she gave birth both in the hospital and in her home, but also gave birth both before and after WWII. Born in 1915 to Ukrainian homesteaders, she raised her family on the farm. The nearest neighbour was between a quarter- and a half-mile away. Her first five children were born at home with a midwife, between 1936 and 1942. The last three children, born between 1946 and 1952, were born at the hospital.

The midwife who attended my baba lived the next section over and was allegedly untrained (formally) and unpaid for her services. This is consistent of immigrant families, who were now detached from their female familial support networks and had to turn to the women of their community for guidance.  This neighbour midwife was recognized by the community as their midwife and attended local women in birth. However, she was not the only midwife in the area, which suggests that there may have been some range or proximity in which these midwives worked. Unfortunately, there are no stories of these births, as baba never shared them. I’m not sure that anyone will ever know her stories. If she were alive today she would be 95 and most of that generation is gone now.

The only memory that my aunty Alice has of the births of her younger siblings, is that she would wake up in the morning with a neighbour lady at the house and my baba would return two weeks later with a baby. It doesn’t appear that she had any prenatal care for these later babies. Likewise, she may have had no prenatal care from the midwife for her earlier births, but with the midwife only a half-mile away one would imagine more support was possible. From my aunts’ perspective, the location of births was dictated by the norm. My baba did what everyone else did, whether that was giving birth at home or later in the hospital.

My grandparents never had a car, nor was there a phone. At first they used a horse and buggy in the summer or a wagon in the winter, eventually they purchased a big tractor, but once they moved off the farm and into town, they bought a smaller john deer. There were two hospitals within 30min to an hour away from the farm. The Canora Memorial Hospital (where the three hospital births occurred, as well as all of Evelyn’s births) was an hour away by buggy and opened in 1913. This was the furthest, of the two hospitals in the region.

There are a few possible reasons why there was a shift to hospital births for the later group of children. In the post-war era, the norms for birth changed, which may also account for the spacing between children. Doctors were eager to prove their knowledge and needed a reliable source of income, obstetrics, like today would have been their cash cow. Doctors and nurses would have set out to “educate” the community on how much safer and superior their techniques and technology was.  In addition, Alice recounts a story where one of the women on the neighbouring farm was giving birth at home in ~1949 with a midwife. Both the baby and the mother died. After this, she believes that the women were afraid to birth at home, feeling the hospital was in fact safer.

The local hospital in Canora, Saskatchewan opened in 1913. Saskatchewan (the birthplace of Medicare) began opening hospitals in any community with at least 200 people at the beginning of the 20^th-Century. The Hugh Waddell Memorial Hospital (later Canora Union Hospital) was initially a mission hospital, run by Presbyterian nuns until 1944 when it was sold and the name changed. In 1914, the hospital had 60 beds and after constructing an additional wing in 1950, reopened with 82 beds. The services were basic and they primarily provided maternity care. The likelihood is that this hospital would not have been equipped to perform caesarians, however, my father says there was an operating room.

By the time in which the woman and her baby are believed to have passed away, my baba had already delivered one child in the hospital. We can assume then that this death was neither her motivation for choosing to go to the hospital, nor was fear of birth itself. Rather it was likely to be simply due to a change in the norms and hospitals becoming the more desirable or acceptable place to birth. Comacchio (1993, as cited in Bailey) identifies that “hospital births were the experience of the majority of Canadian mothers by the mid-1950s...they [hospitals] were perceived to be more convenient and professional”. Based on Evelyn’s experience, we can conclude that twilight sleep was also a component of that convenience. Unlike my aunts, I do not know if my baba was conscious during her hospital births. However, considering that Evelyn gave birth to her first child 6 years later in the same hospital and was rendered “unconscious”, it is likely the same happened to my baba during her hospital births. This is so heartbreaking, particularly because one of these children was my father. 

Bailey (2002) provides us with a synopsis of birth in early western rural Canada. She indicates a pattern similar to what was occurring across North America, but suggests that many of the technological “advancements” in obstetrics and physician led care, did not initially impact rural communities significantly. It was not until after WWII that doctors and nurses began to spread out across Canada and into rural communities. With the emergence of these new care providers and in order to gain access to patients, specifically maternity patients, it appears that they felt the need to discredit the midwives. This historical view is consistent with my family’s birth stories. Their [doctors and nurse] campaign was fairly successful and may be evidenced by the switch from births at home to the hospital by my baba after the war. Biggs (2001, as cited in Bailey 2002) notes that after the war, with the centralization of healthcare, both midwives and in particular nuns lost control over hospitals. This is confirmed by the history of the Hugh Waddell Hospital that was purchased by the Canora Memorial hospital in 1950 from the Presbyterian nuns in 1949 (http://canoraqx.sasktelwebhosting.com/tourism.htm). Lastly, the use of drugs such as scopolamine also supported the physicians superiority over midwives by, as my aunty Evelyn states, “making birth easy” on woman. Although, even though narcotics were being administered, it appears that the use of tools, such as forceps were not, at least not in my family.

The use of instruments brings into question about the motivation for long-stay care postpartum. My aunt is adamant that she had a natural birth. It may be argued that these women were in fact, kept for prolonged periods and pampered for so long to help speed the healing of injuries related to the use of forceps. Evelyn’s confusion and inability to care for her newborn after she left the hospital may have been a response to morphine given to her postpartum to ease the pain from vaginal injuries. It is fairly well documented that Twilight Sleep births necessitated the use of manual extraction of the newborn. Although women were physically functional for their births, they were strapped down to prevent them from leaping out of windows and other self-inflicted injuries related to the psychosis they were under. This has been coined the DeLee technique:

“DeLee’s procedure, which became widely adopted, began with sedation of the woman with scopolamine when labor started. Her cervix was allowed to dilate on its own and she was given ether during the second stage. The doctor would then perform a generous episiotomy, and extract the baby with forceps. Removal of the placenta followed, as did a dose of ergot to help the uterus contract, and the perineal cut was stitched restoring what DeLee called “virginal conditions.” http://www.theunnecesarean.com/blog/2009/12/6/joseph-bolivar-delee-and-the-prophylactic-forceps-operation.html

Is there a generation of women that were subjected to episiotomies and forceps unknowingly? Is my aunt one of these women? It is hard to imagine that a woman wouldn’t know she had an episiotomy or forceps used on her. However, when they have no agency, no education about birth and surrender themselves to the care of their doctor, there is space for ignorance and maybe even denial.

It is appropriate to mention briefly the state of caesarian births, although this is not part of my family’s history.  Alice states that caesarians were not prominent until 1965-1970, with rates increasing in the 1980’s and 1990’s. She equates the rise in caesarians beginning between 1965 and 1970, with the female liberation movement. Women were demanding access to caesarians! This is similar to the demand discussed earlier, for twilight sleep around the beginning of the century. Women believed that by having access to the latest technological advancements in medicine, they were not only educated and part of this cutting edge profession, they were in control of their birth. No longer having to regress to a more primitive state of painful natural birth.

Conclusion

We have seen through the birth stories of my two aunts and baba how there was a shift from homebirths with a midwife to hospital births and twilight sleep. The homebirths were uncomplicated and attended by a lay midwife who lived in a neighbouring section and received no pay for her services. After the war, even though Saskatchewan had a long history of maternity care facilities, birthing shifted from the home to the hospital. Developments in obstetric care occurred later in these rural areas. There is no clear reason why this shift occurred, but it can be assumed that it was an effective campaign on behalf of physicians that needed a clientele base. They succeeded in this campaign by offering excellent postpartum care and providing pain-free births.  In a time that birth was not discussed, agency and empowerment were not concepts that came into play for the average woman in rural Canada. Rather, birth was a normal physiological process that could happen wherever society deemed it acceptable.

   

 

References Cited:

Bailey, Jessica. 2002. The Experiences and Education of Midwives in Three Canadian Provinces: Saskatchewan, Ontario and Nova Scotia

Biggs, Lesley. 2001. “Fragments from the History of Midwifery in Canada: a Reconsideration of the Historiographic Issues”. Reconceiving Midwifery, The New Canadian Model of Care. Eds. Ivy Bourgeault, Cecilia Benoit & Robbie Davis-Floyd. Ann Arbor: University of Michigan: Forthcoming.

Cassiday, Tina. 2006. Birth: the surprising history of how we are born. Atlantic Monthly Press.

Comacchio, Cynthia R. 1993. “Nations Are Built of Babies” Saving Ontario Mothers and Children 1900-1940. Montreal:McGill-Queen’s University Press.

HOBBS, B.Sc., F. S., M.D.C.M., F.A.C.S. and JOHN J. CARROLL, M.D.C.M. 1958. THE USE OF PROMETHAZINE (PHENERGAN) AS A SEDATIVE DURING LABOUR*, Vancouver, B.C.; Canada. M.A.J Nov 15, 1958, vol. 79

Mitchinson, Wendy. 2002. Giving Birth in Canada, 1900-1950. University of Toronto Press Incorporated.

http://canoraqx.sasktelwebhosting.com/tourism.htm

http://www.theunnecesarean.com/blog/2009/12/6/joseph-bolivar-delee-and-the-prophylactic-forceps-operation.html

births

two births this past week. two very different experiences, two very different pregnancies, two very different women.


every birth opens me up. forces me to ask questions. realign. with every birth i grow. i see something new.