Silenced and shamed - speak and reclaim - the journey of a midwife

This midwife contacted me and offered this post for my blog. She wishes to remain anonymous. Her message is hard-hitting, emotive, and real. Please take time to read, reflect and act. 

Image: http://www.freedigitalphotos.net

The book The Roar Behind the Silence: why kindness, compassion and respect in maternity care matters has highlighted issues, and given many practical tools that are so important in the on-going training and care that midwives and other maternity care workers provide. Reading about others’ experiences and gleaning from their wisdom has added jewels to my midwife treasure trove.

I would like to take this opportunity to talk about the “unspoken” and the not so pleasant things, the secrets that many women hold in their bodies, hearts, and minds. It’s my hope that in speaking out about these subjects, that it will give you courage on your road as a care provider, widen your perspective of the women in you are serving, and encourage you to be someone who creates safe spaces for pregnant women to share their situations. Don't be afraid to reach out for help when you need to.  One small opportunity or intervention, on your part may save a life, or two.

We midwives are humans too. 

The Royal College of Midwives chosen charity of the year has recently been announced as Women’s Aid. Women's Aid is a charitable organisation concerned with supporting women who are suffering from domestic abuse.  “Domestic abuse is a significant factor in the ill health and mortality of mothers and pregnant women (1). It can have significant physical and emotional impact on the woman and can lead to miscarriage, low birth weight, ruptured uterus and pre-term labour.” (2) 

Violence and abuse are usually secret and hidden. Victims are shamed into silence by fear and control. 

Women's Aid uses the Home Office definition of domestic violence which is: 
Any incident or pattern of incidents of controlling, coercive or threatening behaviour, violence or abuse between those aged 16 or over who are or have been intimate partners or family members regardless of gender or sexuality. This can encompass but is not limited to the following types of abuse:

• Psychological
• Physical
• Sexual
• Emotional 

As a midwife in training I thoroughly enjoyed studying and learning skills, but when it came to hands on experience it was as if the connection between my acquired knowledge and my physical intuition to connect, was blocked. I knew the kind of midwife I wanted to be, I was surrounded by great role models. I felt disappointed with my apparent dysfunction to give what I had never experienced, human connection,  deficient in oxytocin and the container of it.  I grew up in a violent environment with touch and comfort withheld. I was punished and suffered violence daily, and observed other forms of violence and dysfunction in family life. As a student midwife, I felt extremely uncomfortable to offer any kind of physical reassurance to a woman in labour. Even rubbing her back was a huge obstacle for me. Witnessing someone, struggling to cope alone, and lost in her own fearful space, I was able to overcome my own lack of confidence, to reach out to show her kindness and compassionate care.

Being a midwife is one of the most rewarding life responsibilities in the world if you ask me. It has drawn out the best and the worst in me. It is demanding, pushes all my buttons and takes me beyond the limits I believed I once had. I have always been sensitive to pick up “cues”, to empathise and support, encouraging women to speak up, ask for help, and report violence that has brought physical and emotional harm to them and their unborn child. Some women may not disclose any such events but we can always do our best to create a safe place, following policies, guidelines, and instinct. More on the practical aspects later. A basic bottom line is to always offer your best to each woman, whatever her circumstance. 

We midwives  enter into each appointment / birth experience evaluating what that woman needs to facilitate a good experience for her.

SILENCE - can be a refuge, but it may also be a prison. I spent most of my childhood in silence to the daily abuse I survived. We humans are pretty resilient and we can make it through most adversities, but we carry that stress, the trauma and the memories in our conscious and subconscious being, maybe even epigenetically through generations?  Add the dynamic of pregnancy, hormone changes, physical challenges and life’s daily problems. Women in your care may have already turned to alcohol, drugs, eating disorders, self-harm, or some other self-medication, in order to get through each day, numbing themselves as a self preservation method.  Of course this puts their health and pregnancy at risk, and they need help.

What do you notice when you are “with woman”? Do you notice when someone else is constantly speaking instead of her, keeping her in silence? How about the quiet and shy type? Will she look into your eyes? Does she flynch or jump at sudden noise or movement? Does she “zone out”? Does she come across as passive, agitated, guarded or anxious beyond a typical level?  Do you have women that never come to an appointment alone?

If perinatal mental illnesses go untreated they can have a devastating impact on women and their families. In extreme cases, these illnesses can be life threatening – they are one of the leading causes of maternal death in the UK (3)

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Silence is not always a sign of contentment. Try to make an extra effort to find out the reason behind the silence.

More than 1 in 10 women will be affected by a mental illness during pregnancy or after the birth of their baby (4). This means that each year in the UK more than 70,000 families will experience the impact of these illnesses. We midwives are growing in awareness and our aim is to facilitate women's ablitiy to speak up about their unique situations, decisions and personal needs. 

SHAME - is  'the painful feeling arising from the consciousness of something dishonorable, improper, ridiculous, etc., done by oneself or another'.  Brene Browne defines shame as the fear of disconnection, 'Is there something about me, that if people know it or see it, that I won’t be worthy of connection' 

Do you ever read beautiful birth stories online? Birth story surfing is turning into a competitive sport these days with words and images of joy, peaceful and pleasurable birth, fantastic photography capturing the moment, the idyllic and the organic.

But what about the woman who is afraid to birth? Maybe she can’t quite put it into words but she has an unexplainable fear of a breast or vaginal exam. The thought of breastfeeding and skin to skin could be a challenge that makes her feel like she is suffocating? Maybe her life has been a chaotic and confusing, relational and abusive mess, so the mere idea of such unpredictable, uncontollable events such as labour and birth could be horrifying. There is no rational explanation in her head and it’s not the easiest topic to bring up, especially with her own high expectations of “perfoming” and being the best mother she can be.

In her family, or in her culture, issues of sexuality, birthing, problems and relational difficulties may not  be addressed and she has no confidence, or no one she can trust to voice what she has been through, or what she is constantly living. Perhaps you will be the first person in her life to ask questions that dig a little deeper, and provide an opportunity for help, referral, counsel, and medication when needed. The more we work at listening and observing with all our senses, we can become more sensitive to the women we interact with. 

Image:  canstocck.com

After a lot of theory and learning for my midwifery study, the practical part came along. I was in great anticipation of putting all I had learned into practice. I was shocked by some of my responses. When I had to perform vaginal exams I felt horrible, as if I was abusing the woman. I went to my supervisors on several occasions in tears, and stated that I could not be a midwife because I did not want to do vaginal exams. It was a strong emotion beyond my cognitive mind. My supervisors encouraged me not to give up, and that was it, I pushed through, but I would really have prefered to skip that part. I have since learned to observe and to only do vaginal exams upon the woman’s own request or when the pattern of labour is unusual. Of course they are useful to diagnose an aynclytic baby, or a surprise breech etc. 

Courage brings connection, which defeats shame, so enabling a woman to #breakthesilence of her current, or history of, abuse, in her vulnerability, which in turn will also facilitate the crushing of shame, and light the flame of connection. Where there is no longer fear, love dwells.

Often women who have suppressed memories of childhood sexual abuse (CSA) will start to get flashbacks when they become sexually active, or during pregnancy, labour, or birth. For me the process of being a student midwife stimulated those subconcious memories into that present time, with flashbacks, intense feelings of shame, and an inherent impression that I was doing something wrong, or that I was not worthy to be a midwife. The truth was, I was doing nothing wrong, but the exposure to something new had triggered something hidden. It’s important that you find someone you can talk to if you are struggling with your own responses, or a situation in which you feel needs specialised attention and is beyond your scope of care that you can provide. I have always found that asking for help has been both a relief and a solution to my own struggles in my personal and professional development. I had to take time out at times, to deal with my own issues, so I did not carry them into my work, and to learn to be kind to myself, so I could give compassion to others.

Some women have suffered so much trauma that a vaginal birth is out of the question and an elective cesarean would be a kind and relieving option. Some women need to have specialised care, counseling and yet still be the decision makers for their own care. With the appointing of specialist mental health midwives, women will get the much needed support and counsel throughout the UK. 

We midwives give our best, our combined efforts, together with colleagues bring optimal care and support to women and their families. 

Speak – As I grew as a student or as a midwife my skills have been enhanced. There are study days, conferences, social media, and more, to glean knowledge. I have found that reading books, studying, workshops and team learning opportunities have given me insight and assisted me to grow.

Enhancing my communication skills through observation, reading, workshops, role play, listening, and reflecting have been vital instruments. Consider the language we bring to each conversation. Is it enabling a useful discussion? Is it creating fear or kindness? Women are exploring language and different methods as tools to undergo a gentler birth experience. We can support this by being flexible and giving choice and using alternative words as options. Examples of this are surges, instead of contraction, opening instead of dilation, not putting emphasis on a nuchal cord delaying progress, aiming for the positive rather than bringing a fearful approach. Our verbal language combined with body language and attitude, can make all the difference to how safe a woman in our care may feel.

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The systems in place in hospitals across the UK have plenty of resources, and referrals to a community midwife, mental health midwife, consultant in mental health, community psychiatric services, depending on severity.

If a service is run in a way that enables a woman to see the same midwife at all or most of her appointments, she is more likely to feel able to disclose concerns about her mental health. However, evidence shows that too many women do not receive continuity of care, and that this makes it harder for women to discuss their mental health with a midwife. (5)

We midwives have the tools, skills and resources,  to speak words that enable the woman to be powerful and positive, no matter what their background or current cirmumstance.

Reclaiming something for yourself is an achievement. Overcoming seemingly impossible obstacles can be a daunting, yet not impossible task. Believe me, I’ve done it several times. A woman who has a phobia of needles (a possible effect from CSA, but not solely related) could have a positive experience by meeting a care provider who specialises in providing sensitive and specialised care. I have witnessed a woman completely at ease during a planned elective cesarean, yet previously terrified. After meeting and asking questions from a kind and experienced doctor to perform needed procedures involving needles, she was able to cope remarkably well and even surprised herself. A gentle approach involving the woman in the decision making can make all the difference.

Another woman voiced that she would prefer absolutely no vaginal exams in labour. It was easy to observe, in labour, that she was progressing well, no vaginal exam was done, she birthed in water and was clearly pleased with the birth experience afterwards.

I hear so many stories of women who had a traumatic birth the first time around. For their next birth, they were proactive to seek a different experience. Some choose a homebirth to avoid procedures that had caused stress in their previous birth. I have witnessed firsthand how women reclaiming their birth and their power, their decision making autonomy and their circumstances, go on to birth in a calm, loving and supported manner. What a beautiful way to enter parenting and what an imprint on the baby, begininning it’s life in perfect love, peace and a safe embrace.

We midwives  hold the potential to positively influence society by bringing compassion and kindness to the forefront of our practice.

References:

1. Price, S, Baird, K and Salmon, D (2007) Does routine antenatal enquiry lead to an increased rate of disclosure of domestic abuse? Royal College of Midwifes 

2. Granville, G and Bridge, S (2010) Summary of findings and recommendations from the independent evaluation. PATHway: An Independent Domestic Violence Advisory service at St Mary’s Maternity Hospital, Manchester. 

3. Saving Mother’s Lives: The Eighth Report of the confidential Enquiries into Maternal Deaths in the United Kingdom (2011) British Journal Obstetrics and Gynaecology. 

4. NICE (2007) Clinical Guideline 45, Antenatal and postnatal Mental Health. http://guidance.nice.org. uk/CG45

5. MMHA SMHMs Report P.6