Tuesday, October 25, 2005

An Education in Care

If you want to get the inside scoop on birthing practices in BC, stand outside a kindergarten classroom just before the end of the school day. You’ll find a group of young mothers, with babes in arms, waiting to pick up their 5 year olds. They’ve been through the system - probably a few times - and are only too happy to share their hard won stories. Ask about their first birth experience, and you may hear stories of disillusionment, loss of dignity, overcrowding, or lack of continuity. They’ll tell you they wish they’d been better informed, and had known enough to find great caregivers.

Then there will probably be one woman in the group who shares her second birth experience, and shyly admits to feeling joy. “What a difference my second birth was!” she’ll say. “It was like night and day!” You might hear her talk about empowerment and laughter. What was the difference from her first birth, you ask? “Oh, I changed caregivers...and I hired a doula.”

Sadly, the majority of us stumble onto our maternity caregiver. Perhaps our family doctor doesn’t provide obstetrical care any more and refers us to a local obstetrician. Perhaps a friend gives us the name of the doctor who performed her D&C last year. Since there is often an element of surprise involved in the discovery of our first pregnancy, very few of us have the luxury of time to research the variety of available care in our area.

We are also victims of American media, watching their TV shows and reading their books, and mistakenly believe that an obstetrician will provide us with the best care possible. The system in BC is quite different from that in the U.S. The obstetrician doesn’t necessarily provide the best care for our particular needs (this is quite separate from being a good caregiver) - and most assuredly does not provide the greatest continuity of care. Many of the obstetricians that I work with will be the first to admit that their skills are best utilized by those who truly need them, those at high risk, and not by the average normal healthy pregnant woman. “You don’t want to see me walk back into this room,” said one obstetrician to my client the other day, after consulting with the woman’s family doctor. “I’m the surgeon.” Happily, this woman’s labour ended smoothly, without further consultation from this wonderful obstetrician.

Here’s the explanation provided by the BC Women’s Family practice Maternity Service: “In BC, family physicians, registered midwives, and obstetricians are all licensed to provide maternity care. Women can see any of these three caregivers: however, obstetricians are specialists with extra training in surgical skills and management of complicated pregnancies. They typically see women with complex pregnancy issues. Most women see either a midwife or a family physician. While both midwives and family doctors provide excellent care for the expectant mother, choose the caregiver that makes you feel most comfortable.”

In terms of continuity of care, your own family physician, if skilled in the area of obstetrics, might perhaps be your choice. This person would have prior knowledge of you and your family, be able to care for you during your pregnancy, both obstetrically and medically, and provide postpartum, baby, and family care afterwards. However, this “small-town” approach is rapidly disappearing.

Many family doctors these days have withdrawn obstetrical services due to time constraints, increasing insurance costs, or lack of experience in this area. Increasingly, family doctors refer their pregnant patients to another caregiver. It is worth doing as much research as possible before accepting a referral for maternity care. Know your options, then make an informed choice about your maternity caregiver. This decision will determine the standard of care for your birth experience, perhaps one of the most important experiences in your life. So take your time.

Regulated in BC since 1998, midwives are experts in healthy pregnancy, normal birth, and well babies, and are respected members of the BC medical system. Midwives attend births both at home and at hospital, following strict protocols governing safety. Their services are covered under the BC Medical Services Plan.
The Midwives Association of BC website includes listings of midwives in your area. The College of Midwives of BC website provides more in-depth information on the model of care, standards, and education.

For those women whose family physicians no longer provide obstetric services,
BC Women’s Hospital, Royal Columbian Hospital, and Lions Gate Hospital all have family practice maternity services. The doctors at these clinics are general practitioners who specialize in obstetrics. These doctors work in rotation to provide prenatal and birth care. At St. Paul’s hospital, there are some more informal groups of family physicians who will accept referrals for care during a woman’s pregnancy.

If pregnancy complications arise, both the midwife and family physician consult with other medical personnel, but remain involved in your care. If either the midwife or family physician requires an obstetrician’s consultation, then they are often able to select the caregiver most compatible with your personality, and most competent to deal with your particular concern on that day. This part of their service is particularly critical these days, with hospitals being stretched to their limits.

So, what are the odds of having your own midwife or doctor attend your birth? Midwives generally work in teams, with perhaps two or three midwives working in rotation. At a home birth, there are always two midwives in attendance. Continuity of care is of great importance. Very few doctors take all their own calls. The majority of family practitioners work in call groups of up to six doctors, working shifts of 24 hours. Some attend their patients’ births during the week, and rotate call on weekends. Many of the groups have “Meet the Doctor” nights, where you can visit with all the doctors in the call group, and listen to them talk about their philosophy.

If your pregnancy is complicated, or becomes complex, you may be working with an obstetrician through your labour. Remember that all obstetricians work in large call groups (of 8-20+ OBs), and are on call for 12-48 hours at a time. During that time, each obstetrician is responsible for his or her own patients, plus the patients of the other physicians in the call group. Because of the surgical work load, and for teaching purposes, an obstetrician relies on an obstetric resident to provide care for the woman in labour. Either the resident (junior and/or senior) or the obstetrician (or all) will be present for all procedures, and at the birth. At these more complex births, the nurse’s role and the doula’s role are critical. Since the physician who you have seen in your prenatal visits is unlikely to be present for your birth (or busy in the OR), the nurse and doula are left to provide continuity of care, and to work closely together to complete a multitude of tasks. Highly technical births need that extra bit of human touch, and we must all work diligently to make you feel honoured and empowered during this more challenging experience.

In all cases, whether you work with a midwife, a family physician, or an obstetrician, I will work with your caregivers to provide continuity of care. I will act as “translator,” working to facilitate open communication between you and the medical staff. I will provide physical and emotional support for you and your family, and make sure that you are provided with all the information so that you can always make informed decisions. I do my best to help you feel empowered by the process, to feel safe.

And I hope that, when you are that mum standing outside the kindergarten classroom, you will share your birth story and be able to smile and say, “I’m so glad I had such great care...and my birth was great - it was challenging, but it was amazing!”

- Jacquie Munro - Vancouver Doula, Slow Birth, Slow Planet

Sunday, October 16, 2005

Full in the hand / Heavy with ripeness

For Maddox

To feel a baby's head for the first time
full in the hand
heavy with ripeness
is a sacred act

To feel the vernix slick
the fontanelles molded
the marble-hardness
the heat of it all

The sensation remains in my hands still
more than twelve hours later

Necessity made me reach down
to slow this baby's arrival
to make him come gently

I called for her to touch her baby next
and she did
but she should have been
the first
to feel her baby touch the air

a sacred first

I will guard this feeling

the baby's wisdom remaining
on my fingertips

“Full in the hand/heavy with ripeness” are two lines from a Marge Piercy poem about love-making. I have always loved these lines, and thought that they could also refer to a newborn at birth. But I had never fully experienced that connection until I held Maddox’s head in my hands. Until then... I was never moved enough to spill the remaining lines of my own onto the page. - Jacquie Munro, Vancouver Doula

Friday, October 14, 2005


1/3 cup fresh lemon juice
1/3 cup liquid honey
1/4 teaspoon salt
2 crushed calcium/magnesium tablets
plus enough water to make up 1 litre

Blend together and pour into ice cube trays or drink "straight" during labour.

The Doula Solution

Here's an article from the Winter 2001 issue of

Western Living Magazine about my doula service:

When the contractions begin and even Dad starts screaming for drugs, a little backup is a good thing.

Six hours into labour, Dad's feeling like a third wheel at the bedside. He wants to help, but he's not sure how.

"What does it feel like?" he asks his wife.

"Sour!" she hisses.

Sour? He has no idea what that means.

"It could be lactic acid she's tasting," explains the ultra-calm woman who has been massaging his wife's feet for the past three hours. "The uterus is a muscle and it's working hard. This is perfectly normal." It occurs to this man that a stranger is sharing the couple's most intimate moment. And damn, but he's glad she is.

She's a doula. "I'm labour support," says the veteran Vancouver doula Jacquie Munro, 'although when I tell people that, they think I work in union administration."

"Certified doula" is a job title that would scarcely have been imaginable earlier in history, or in a less driven culture. (Extended family or a community elder would have helped a mother through her delivery.) But somehow it's fitting that, in the age of the private trainer, more couples are embracing the idea of a personal birthing aide.

A doula is not a midwife, she isn't licensed to intervene medically; she has no particular agenda with respect to drugs or childbirth methodology. You might think of her job as simply full-service care from the ribs up (foot massages notwithstanding). Whatever needs doing - from decoding physician jargon to wrangling agitated relatives or zipping home to feed the cat - the doula just handles it. "I'm kind of the little guardian angel who just makes sure that everything is running smoothly," says Munro, a former graduate student of developmental psychology who also taught the first course at Douglas College's doula program. "I'm also the walking encyclopedia. I don't tell people what to do, but I do give them the tools to help them make informed decisions."

You're not alone if you've never heard of doulas. The term was only coined in the early 90's and derives from a Greek word that means an experienced woman caregiver of another woman. "I think they found out, actually, that it almost means slave," says Munro. "Historically, that's who was looking after other women in labour."

Munro noticed a spike in demand for doulas around five years ago as word spread, via the prenatal-class telegraph, about this option that radically reduced stress and the chance of knifework in the delivery room. There are 475 Canadians registered with the 2,500-member strong Doulas of North America Association (DONA). but since registration isn't obligatory, the actual number of doulas working in cities across Canada is unknown.

Because the doula business is, well, in its infancy, a certain amount of confusion surrounds it. For one thing, the term is understood to mean different things in different places. In New York, where hiring a doula has become de rigueur among turbo-professionals, the doula isn't present at the birth; she's sold more as a housekeeper. "Some doulas literally move in the day you get back from the hospital," explains Vancouverite Sara Dubois Phillips.

Dubois Phillips's husband hired a doula for her as a surprise gift when she was pregnant in Manhattan - though the arrangement proved a bit claustrophobic. Still, says Dubois Phillips, there were initial benefits: "She could tell me how other women had handled what I was going through, because at that time none of my friends had kids. That's why doulas are such a phenomenon in a place like New York, where everyone is a transplant."

The doula is a support system for both partners, but dads seem to benefit most - especially in late-stage labour. When he needs sleep, she spells him off on the back massage. If he starts to flip out, she quietly, constantly, feeds into his ear what guys crave most: data.

"My job is to make him look so good - without being condescending," says Munro. "I try to ensure that he's directly in her line of vision, so that whenever she opens her eyes, he's there. I'm putting the drinks in his hand. I'm handing him the cold cloth. And all she knows is, He's incredible." - Bruce Grierson

Thursday, October 13, 2005

CBC Radio is back!

What’s the connection to this blog? To birthing and mothering? Well, CBC Radio has been the backdrop to my life. It formed the beautiful predictable ritualistic structure for my mothering at home.

CBC Radio 1 has brought form to my life, acting as “comfort food for the mind” when I was a child, bringing sanity to my early years as a new mother, and helping me to parent young adults consciously and conscientiously. So, rather than encouraging new parents to seek out parenting information from "The Baby Whisperer" or other books that address structure and scheduling, I just encourage new mums to stave off loneliness, provide intellectual stimulation AND provide structure by simply turning on the radio.

“As it Happens” meant that it was dinner time when I was a child. “Morningside” with Peter Gzowski brought structure to my mornings when my own children were small. The sound of the beeps which signal 10am meant that I should put the kettle on for a relaxing cup of tea. The noon news reminded me to put aside the playdough and make lunch for us all. The Wednesday morning political panel of Stephen Lewis, Eric Kierans and Dalton Camp was always on the radio in the car as I drove to my midwife appointment during my second pregnancy. Once my children became readers, I would wait, pen in hand, to listen to Michele Landsberg's (incidentally, Stephen Lewis' wife) book recommendations. And in more recent years, some of my clients at home or hospital have turned on CBC Radio 1 to bring some predictable structure to their labour. One woman deep in labour told all the staff to be quiet at noon on a Sunday, just so that she could listen to Stuart McLean tell the Christmas Turkey story on “The Vinyl Cafe,” in between contractions.

Research has shown that one of the best predictors of superior brain growth and development in children is the amount that a parent talks to a baby during the first year. I didn’t read, sing, and chatter to my children to “make” them into something, but to honour them as the complete little people that they were. So, I’d be working in the kitchen, listening to a radio documentary, and asking my three month old daughter what her opinion was. In the early 1980’s I remember talking to her about a newly discovered disease called AIDS and whether the Russians invasion into Afghanistan would precipitate a global war. I remember feeling so strongly that I was helping my children to grow up as critical thinkers - even at such a young age. And they would look at me with such knowing looks, like all of this wasn’t news to them...

I also remember cuddling up in afternoons, listening to the presentation of the Classical Kids Series of radio plays, like Beethoven Lives Upstairs and Mozart’s Magic Fantasy. I knew I was encouraging my children’s imaginations. In a world increasingly full of speeding images on TV, and the manic fever pitch of video games, I could provide my children with the gift of visual images that can never be duplicated. I knew that each child curled around me was seeing a totally different scene. Perhaps that led to their love of theatre, personal expression, and intellectual bravery.

So, it was with great anticipation that I turned on the radio early this week, waiting for live radio once again. I was looking forward to a new season of “As it Happens” and “Sounds Like Canada”. I was looking forward to listening to the CBC overnight service (a doula’s life involves a lot of driving at 2am). And what was the first thing I heard when I turned on CBC Radio 1 for the first time in months? An advertisement for Stephen Lewis’ October 18th "Race Against Time" Massey lecture at the Chan Centre. I must go listen to him - and take my family.

Things haven’t changed a bit.