Tanya Strusberg, LCCE, FACCE is a member of the Lamaze International Board of Directors, and the founder of birthwell birthright in Melbourne, Australia. She reviewed midwife Rachel Reed’s new book “Why Induction Matters” for Science & Sensibility last month. She is also the author of the internationally respected blog, Midwife Thinking. Today Tanya shares the second part of her coverage on this topic with an interview with Rachel Reed Ph.D. - Sharon Muza, Science & Sensibility Community Manager
Tanya Strusberg: Can you tell our readers a little bit about yourself?
Rachel Reed: I lived in the North East of England until 2005. I now live on the Sunshine Coast, Queensland, Australia in a little house in the middle of a forest with my husband and various birds and animals. We have two grown-up children, both born in the UK before I was a midwife.
I work at the University of the Sunshine Coast as a senior lecturer and discipline lead for midwifery. I feel very lucky to have a job that allows me to teach, research and write about birth and midwifery. This opportunity was not something I expected when I left school pregnant with no qualifications!
TS: You’ve practiced as a midwife in the United Kingdom and Australia. What are some of the differences you’ve experienced in clinical practice?
RR: The Australian maternity system is a hybrid of the UK and US systems. Clinical practice in the public system is very similar to the UK, and in the private system, it is similar to the US. However, in terms of the midwifery profession, Australia is very different. I experienced a huge culture shock when I arrived.
Midwifery as a separate and autonomous profession is well established in the UK. Every pregnant woman is allocated a named midwife and the general public know what a midwife is. In Australia, midwifery is still struggling to be acknowledged as a separate and distinct profession. Midwifery is perceived as a branch of nursing, and the medical profession continues to actively resist and limit women’s access to midwifery models of care. This reflects the history of midwives, doctors, and nurses after the colonization of Australia by Europeans. Doctors wanted control of the ‘market’ i.e. birthing women. However, women continued to employ midwives as they had in Europe. Long story short – the doctors combined forces with the nursing profession to bring midwifery into nursing and regulate midwives through medicine. This strategy was very successful.
In the UK, community midwifery and homebirth is an integral part of the public system. Women have the right to choose where to birth, and maternity services have a duty to provide care. In Australia homebirth as part of the public maternity services is fairly new and limited. After a few years in Australia, I left the public system and set up as a private midwife because this was the only way I could work to my full scope in my local area. I was missing the relationship aspect of continuity of care midwifery. At that time, independent midwifery was fairly simple. Women employed me directly, I provided care based around their needs and preferences liaising with other care providers and hospitals at the woman’s request. Unfortunately, this way of working has been systematically eradicated with private practice midwifery being regulated away from women, and towards institution (and insurance) centred care.
TS: With all your academic and writing commitments, do you still have time to practice as a midwife?
RR: No. A few years ago I chose not to jump through the ever-increasing hoops required to continue in private practice. Private practice midwifery is no longer the simple mother-midwife relationship it was. I have great respect for those few midwives who have persevered and continue to provide woman-centred care in spite of all the red tape and hoop jumping.
I have also accepted that I cannot do everything and need to focus my energy where I can make the most significant contributions. For me, that is in teaching, writing, and research. My focus is on improving the experience of birth for all women, in particular, those who birth in the public maternity system. This requires midwives to provide woman-centred, evidence-based care to all women and to advocate for a cultural change.
TS: In your opinion, what are the biggest obstacles facing women today wanting to birth normally, and without unnecessary intervention, and what advice would you give them to help them improve their chances of achieving a normal, physiological birth?
RR: Women’s biggest obstacle is the birth culture, which reflects historical beliefs about women and their bodies. Law and religion have controlled women’s bodies and reproduction for thousands of years. Early science and medicine considered the female body to be a deviation from the superior male body; and its function to be disordered and dangerous. These attitudes underpinned the development of the modern maternity system. Unnecessary intervention is a cultural norm, and physiological birth is a rare event. Many care providers have never seen a physiological birth, and don’t know how to facilitate an environment to support physiology. Care is fear-based which becomes a self-fulfilling prophecy. Routine interventions are carried out due to a lack of trust in women’s bodies and a fear of complications. Those interventions often cause complications that require further interventions. This reinforces the belief that birth is dangerous and requires routine intervention.
General factors that improve the chances of achieving a physiological birth have been well researched and include: midwifery-led continuity of care; an out of hospital birth setting (home or birth-centre); a healthy pregnancy/mother and baby; avoidance of routine interventions.
I also think it is helpful for women to consider birth as their rite of passage. They are the person travelling through this intensely transformative experience. They have the power (and responsibility) and they are the expert when it comes to their own body and baby. Preparation for physiological birth should focus on reinforcing self-trust and embodied wisdom.
If the woman is planning to birth in a maternity system/institution she needs to know her rights and how best to navigate that particular system. Writing down decisions and preferences gives care providers evidence of what you want. Having an advocate (e.g. a doula) allows the woman to get on with birthing rather than having to enter into discussions – which interferes with physiology.
TS: Your new book, Why Induction Matters, is a book I think every pregnant woman needs to read. What made you pick induction as the topic for your book?
RR: I was invited by the publisher (Pinter & Martin) to write the book as part of their ‘why it matters’ series. I knew that this was an important topic for women because my blog posts about induction are very popular, and I often get asked to speak about the topic. The rates of induction are increasing every year alongside the list of ‘reasons’ for intervention. Women are often making the decision to have their labour induced without adequate information. I have had some lovely feedback from women, doulas and midwives about how the book helped decision-making about induction.
TS: I particularly liked the section in your book where you provide information to help people to write a birth plan based around an induction of labour. Many women write a Caesarean birth plan, but given almost as many women are induced as end up giving birth via Caesarean, it makes total sense to create birth preferences around induction. Was this something you planned to include in the book from the outset, or did you arrive at that decision more organically?
RR: I wanted to include the birth plan chapter from the beginning. The chapter consolidates the information shared in the book and facilitates systematic consideration of options. Birth plans often focus on avoiding intervention and facilitating a physiological birth. There is a sense that once birth becomes medical, decision-making stops. However, there are always options, and women should always be in control of what is done to them and their babies. Birth is a transformative experience and can be empowering regardless of how the baby is born. An induction birth plan also helps to communicate to care providers what the woman wants and can guide discussions and practice. It indicates that this woman had made considered decisions and is taking responsibility for her own experience.
TS: Last year when the results of the ARRIVE trial were published, normal birth advocates voiced their concerns that this would steer even more women towards medically unnecessary inductions. Do you think we are starting to see this happen?
RR: Yes, this is happening in Australia, and reflects how evidence is used in maternity care.
The ARRIVE trial reinforced the cultural norms in maternity care. It provided the ‘evidence’ to support practitioners doing what they already wanted to do. Other research contradicts the ARRIVE trial findings, but those studies have been ignored in favour of this one study. There have been a number of extensive critiques of this research (including by Henci Goer on Science & Sensibility).
When research aligns with cultural norms it is swiftly implemented into practice. This also happened with the Term Breech Trial in 2001. Overnight c-section became routine for breech babies and vaginal breech birth became a rarity. We are now trying to reverse this cultural norm and re-educate care providers about supporting breech vaginal birth.
At the same time, we have to provide exhaustive research evidence to support not doing interventions that were initially implemented without any research (e.g. premature cord clamping). Waterbirth is difficult to implement into hospitals despite all the evidence supporting it.
TS: As Lamaze childbirth educators, we strive to support normal, safe and healthy birth and to provide current, evidence-based information to our clients. What would you say are the most important tools we should be passing on to pregnant women and their partners?
- An understanding of the physiology of birth: This isn’t necessary for birth because the body already knows how to birth. However, it can be necessary when planning an environment to support physiology.
- An understanding of the maternity system: That it is set up for a large general population, not an individual; and that the practices are primarily based on cultural norms, not research.
- An understanding of the rights women have within the maternity system: They are supported by law to make decisions outside of recommendations and do not have to provide evidence to support those decisions.
- Tools and approaches for making decisions: The BRAIN tool is great for decision-making around a specific option. Also learning ways to ask questions of care providers to assist with decision-making.
- Reclaiming the childbirth rite of passage: Exploring their experiences of other rites of passage e.g. menarche and how that relates to their childbirth rite of passage. Childbirth is a transformative process that influences women’s sense of self. Women can consider what this means for them and what they need to support their transformation into ‘mother’.
TS: What’s your next big project? Are you planning to write any more books?
RR: This year is filled with lots of speaking engagements and a couple of research projects. I’m hoping to publish the findings of a study exploring women’s decisions and experiences of birthing the placenta.
And yes – I am writing another book. This one is about childbirth as a rite of passage and reclaiming that transformation in current birthing context.
About Tanya Strusberg
Tanya Strusberg is a member of the Lamaze International Board of Directors, the founder of birthwell birthright and the co-founder of Lamaze International Affiliate: Lamaze Australia. She is a Lamaze Certified Childbirth Educator, Lamaze Program Director, and birth doula. She is a passionate advocate for women’s maternity care and her articles have appeared in The Journal of Perinatal Education, Australian Midwifery News, Science & Sensibility, Interaction – the journal of the Childbirth and Parenting Educators Association of Australia (CAPEA), International Doula, Empowering Birth Magazine and Rockstar Birth Magazine. Last, but absolutely not least, she is also the mum of two beautiful children, her son Liev and daughter Amalia. She lives in Melbourne, Australia.