Episode 13 - Birth mapping
Mel:
[0:00] Welcome to the Great Birth Rebellion podcast. I'm your host Dr Melanie Jackson. I'm a clinical and research midwife with my PhD and each episode I cast a critical eye over current maternity care practice by grappling with research and historical knowledge to help you get the best out of your pregnancy, birth and postpartum journey. In the interest of keeping this podcast completely free to you, this episode is sponsored by my dear friend, Poppy Child from Pop That Mama. She's a doula and hypnobirth practitioner and her online hypnobirthing course, which is called The Birth Box, has already helped thousands of women. I'm so picky about who I allow to sponsor this podcast, but I really get behind the work that Poppy is doing. What I love about The Birth Box is that it's so practical. She's had so many amazing reviews and results from the work that she's offering women. In the birth box, you'll learn the tools that you need to manage the pain of labor and also stay steady and calm your nervous system during this really big event.
Mel:
[1:09] The mindset that you get from doing hypnobirthing and more specifically, the one that Poppy has put in the birth box, it works when the big day of birth comes, but also in the big days that will follow in your life as a parent. And there's a little cherry on top in the birth box. It's called the oxytocin bubble, and it's a full album of soundtracks to guide you through labor and help you stay in the zone. The birth box has been rated five stars across the board. And with my code, Melanie, you'll get 25% off at the cart. So if you're preparing for birth, go to the checkout. You'll be so glad you did. The link is in the show notes below. Use the code MELANIE for your discount.
Mel:
[1:51] That is the birth box by Pop That Mama.
Mel:
[1:54] Welcome everybody to today's episode of the Great Birth Rebellion podcast. Today we're talking about birth mapping with Dr. Catherine Bell. Because she's just finished a PhD on this exact topic of birth mapping. So I've invited Catherine to talk about not only her research, but what birth mapping is, how it's different to birth planning, and the conversation is going to go in all directions, I'm sure, because this is a topic you're very passionate about. Can you, in your words, introduce yourself to our audience if they've not yet been familiar with your work or who you are?
Catherine:
[2:30] Thanks for having me, Mel. I am Catherine Bell with a capital M, Mother. I came to this journey as a disgruntled mum who happened to have a scientific background where my next step was a PhD. I had done a master's in science communication. And as I was navigating early motherhood, I'm like, this communication is not working. There was so much that was on a needs to know basis. And so over the course of having four babies, I developed this process called the birth map, which worked for my brain. And as I shared it with other mums, I realized it worked for their brains. And this process came about from documenting all the questions that mums wish they knew to ask. And I realized that women didn't necessarily need information, but they needed questions so that they could seek the information that was most relevant to them. And so I then took that scientific background and applied it to this idea and
Catherine:
[3:44] entered the world of PhDing.
Mel:
[3:47] And when did you build the birth map? Because it's been a thing for a while.
Catherine:
[3:51] It um it first occurred to me in 2014 so it's now a decade into this journey um so for many for many listeners they'll be like never heard of it before whereas for me it's like oh my god that is so a decade ago but it was and it came about when I was trying to birth plan and and the word plan was just walls would go up, eyes would glaze over, and they'd be like, oh, she wants to plan something that's so unpredictable. But the way I was doing it, it had multiple pathways, and I was thinking of journeys, and where is this going to take me? What are my opportunities along this journey? And as a visual person, as I was writing it all down, I went, oh, that looks like a map. And Googled, you know, what's a birth map? Has someone done this before and realized I'd invented something? And so starting to play with it over the next few years before it finally got to the point where this is ready to study. This is where we are now.
Mel:
[5:01] Right. Because there's a book and there's a game and you've got a website dedicated to the birth map. and we'll make sure that in the show notes,
Mel:
[5:08] everyone can find all of that. And we'll talk about that whole kind of the job of birth preparation later in the podcast, because there's a really big argument about, gosh, we just keep giving women things to do or constantly in preparation for the birth and, oh, now you're going to read this and listen to this podcast and do this birth map and now the plan and, oh, it's just overwhelming. So I'd really love to explore that idea of, are we giving women another job to do? But before we move on to that, traditionally, birth plans have been this little like template tick list. So do you want a physiotomy? Yes, no. Do you want an induction? Yes, no. How would you feel about, you know, this, that, and that, and vaginal exams? Whereas I feel like the birth map is more nuanced than that, is it sort of goes, hey, in which scenarios, yeah, okay, tick, you don't want a cesarean section as your first choice. But under which circumstances would cesarean section become your first choice? And, you know, and this is a way for women to understand that decisions aren't really black and white in maternity care. They are ever-changing and very dynamic.
Mel:
[6:18] Which I imagine is where your brain went with this mind map that sort of started from a little bubble and then had all these little offshoots and went if this, then this, if this, then that.
Catherine:
[6:29] Sort of, yeah. We've got pathways and possibilities along the way. But it was born out of the birth plan. So it's like an evolved birth plan. And it needed a different name because it needed to be differentiated from this vague idea of what a plan might be. And the word plan was really problematic. When I started using the word map, I found that eyes got interested, ears opened up. And I was like, oh, this sounds like you're open to flexibility. And that was the real key difference. Was even though birth plans can be written in a flexible way.
Catherine:
[7:17] The word plan seemed to shut down that idea that this was a flexible thing. It was a professional autonomy was one of the things that came up in the literature that professional autonomy was somehow threatened by the birth plan because it was suggesting that you have to do this a particular way and you have to guarantee an outcome, which from a care provider point of view, I can't guarantee that because there are some things that are unpredictable. So the birth map had started out as a birth plan template. And this was when I did my doula training in 2014. And this template was provided as part of the training. And it was quite comprehensive. But as each woman I supported, I'd say, oh, actually, I've just added a few details into the template. it. And then listening to more and more women, oh, you know, I'm going to add that in too. And then I accidentally wrote the book. So the book was, I never intended to write a book.
Catherine:
[8:22] Set up my you know my process was to just write a really good birth plan template with all the things in it that needed to be in there and as it grew into this book-sized thing I realized that templates were restrictive and that it was the questions that mattered so as I would ask women these questions it actually prompted them to say I actually don't know enough about that to be able to answer the question. How do I find out more? Why would I say yes? Why would I say no? When would I say yes? When does that become my safest option as opposed to something that is still an alternative and there's other pathways available? All these words that related to journeys came up, navigating birth, pathways, journeys.
Catherine:
[9:14] Options, and birth plans that were really thorough would have plan A and then plan B and plan C. And if you ended up on plan C, it felt like a failure. It felt like somehow something had gone wrong for us to end up on plan C. Whereas with the map, it felt like I'm making the best decisions based on the circumstance that I'm facing. And the women in the study, that theme came up again and again was, I knew what my options were and I was able to make a confident decision. And so that also became another change of language from informed decision to confident decision. And this was because the women weren't just using the information they were receiving, but they were placing it into their context.
Catherine:
[10:11] This context was their personal life, their individual needs and values, and they were able to take that information and integrate it into their self. And then make a decision that was meaningful to them. And this process was called sense-making. And it was like as this started to unfold in the study, I'm like, no wonder this was working because it gave women the opportunity to make sense of what was happening. And to be able to do that hypothetically meant that when birth was unfolding.
Catherine:
[10:49] They could recognize that they were coming to a point in their journey where their next best decision was actually to go towards intervention rather than to keep trying to stay away from it because they saw that this was the point where I'm now safest going in that direction. So the women that were choosing intervention were doing it very consciously. It was very much a choice. And this idea of consent suddenly became this, like this is what consent's supposed to be. An absolute, yes, this is where I'm going because this is what I want, as opposed to, oh, I'm saying yes, but I don't either really understand or I'm feeling pressure. You know, there's that undercurrent of if I don't say yes, is something going to be, you know, is it more tense? Is there something that feels like pressure to say yes? That pressure was gone. And the women were able to say, I actually had a conversation. I felt seen and I felt heard. And that seemed to be the difference between trauma and acceptance. So even if they're choosing intervention and it might be a cesarean, they didn't set out to have. They could see why that became their best option. And so it was the difference
Catherine:
[12:11] between acceptance and trauma.
Mel:
[12:14] I love what you're saying because really this whole podcast is about experiencing something great, whatever the scenario is. And people look at me weird and they're like, what do you mean? How can I have a great birth if things go wrong at every corner? And as you were talking, I was just reminded of this client that I had who had the most traumatic first birth. And she had a cesarean that she didn't want after an induction that she didn't want. And she contacted me basically saying, I want something, I need something completely different. I want my own midwife. I want a home birth. I thought, right. And I knew how meaningful this was to her. Fast forward to 42 weeks of pregnancy and eight days of prolonged labour with very little progress. And she looked at me and she said, I'm ready for a cesarean section. And we went to the hospital and the doctor listened to her and saw how upset she was when he told her it was going to be hours and hours before they could even offer her that. And when he did see how upset she was, he immediately went, just wait here for a second. I'm just going to see what I can do. He went away and he came back and he said, we can get you in now if you want to go now we can get you in now and she went willingly
Mel:
[13:38] Accepted what was what happened she came to me with the decision of hey I'm ready for a cesarean you know I turned up for day eight of labor and went okay what's the plan she's like take me to hospital and I thought oh man I'm gonna need to work with her closely with a lot of care afterwards because maybe this is going to layer the trauma that she had from the last experience. But she was glowing. She said, I can't tell you how great this whole experience has been. I'm so happy. And I thought, do you know what? This is not about the unplanned caesarean that she had. But the whole time she made the decisions, she knew, as you said,
Mel:
[14:21] she knew what her options were. She decided, everyone around her rallied and went, right, the plan has changed, her decisions have changed based on the circumstance. What can we do to make this experience the best for her, even though it's plan C? It's like it was plan Z on her original menu, yet then by the end, she welcomed it and wanted it. And I feel like that's what you're talking about with what you just described.
Catherine:
[14:49] Yeah. Absolutely.
Mel:
[14:50] And this is what I mean. She had a great, what she would describe as a great birth. And she did all of that, what you were describing as like, okay, we've reached a fork in the road. what's the next best option, even if it wasn't my first choice, what's the next best choice?
Catherine:
[15:07] Absolutely.
Mel:
[15:08] Yes. I love that finding because it really explains that you don't have to have the great and most sort of the top. Option that you wanted in order to still have the most incredible experience for your birth.
Catherine:
[15:24] This is absolutely true. Yes. And it's because it's a journey. It's understanding that sometimes things unfold differently to what I may have envisaged. And there's a lesson in everything. And if we're open to it, we get to the other side and we are stronger because we were part of that transition. And that's why it's not in the study, but as a little sidetrack,
Catherine:
[15:52] that word matrescence is so powerful these days. I didn't have that word when I had my babies, but as it became available to us again, even though it's been around since the 70s, that TED Talk that brought matrescence back into the vernacular. And that word was an anchor. We are going through a transition.
Mel:
[16:15] There
Catherine:
[16:16] Is a journey here and a challenge means growth and like how exciting is that and we don't give that gift to women when we in in sort of the standard approach to birth it's like oh you know painful difficult as a bad thing.
Mel:
[16:32] It's like
Catherine:
[16:33] This is an opportunity for growth you are becoming mother this is incredible.
Mel:
[16:39] And you so you created the birth map and then you thought mate I need to test this thing is it good is it valuable is it offering any benefit to women and so this is what you did your whole phd is kind of testing the concept of a birth map and and then so we've got a paper that came out and we'll absolutely link that in the um in the resource folder and everyone can read it it's full text it's like you can just find it online guys it's One thing that you mentioned in the paper that you found is that the negative
Mel:
[17:12] experiences that women had with the map weren't related to the product itself. It was more related to a communication issue between the woman and their practitioner. I don't want to use lack of respect for the woman's map, but the woman didn't feel like she was able to communicate the work that she'd done and have that practitioner work with her in that journey. Can you explain what happened when some women, not all women in the study, didn't quite get the attention in the story I described that that woman had me as her midwife and an attentive doctor who made things happen and who listened and really helped facilitate her plan? What happens when women don't have those people?
Catherine:
[17:59] Yeah, this was perhaps the most critical finding because this is the finding that needs to be addressed in a systematic change way. I really would have loved it if the finding was birth map, magic, have that, do that, here's the book, problem solved. But it only builds half of the bridge. And for women in fragmented care and in private obstetric care, There was a barrier that came up commonly in those care models where short appointment times and dismissive care providers, not necessarily disrespectful, but dismissive care providers. And this dismissal could be done very gently, very nicely. And it might look like the woman came in with her questions. She had a hypothetical or a what-if scenario that she wanted to map out and she would ask her question and the response she would receive would be something like that's what you've got me for I'm here don't worry about that if that were to happen we'll deal with it at the time and in the moment this was received as reassurance and so they would leave that
Catherine:
[19:17] meeting going yeah yeah, my care provider's got my back. But as the birth unfolded and then in hindsight in the interview afterwards.
Catherine:
[19:27] The reflection was I actually would have preferred an answer to that question.
Catherine:
[19:32] It really would have been helpful to have known what that scenario could look like in advance because I needed to do different things, whether it's a mindset change or having a particular support person in backup. So if it became a cesarean, knowing that the baby was going to be accompanied by the partner, but who was going to come in and support the mom and make sure that there was communication between NICU and baby in the event, of a separation. So in hindsight, they wanted an answer to the question. And that's such a simple solution. Care providers, just answer the questions.
Catherine:
[20:15] But in practice, it's not necessarily as simple. And some of the barriers for care providers might be policies as well. So there are different policies that might sit in their institution that might limit some of the opportunities that they could offer to women. So there needs to be really good referral pathways if there is a misalignment between the decision the woman would make and what's on offer in the facility. But that limitation of appointment times as well. And the women, when they did push their care providers for more information, they did get more time but the women were so conscious that there are other women waiting in the wings for their appointment so they don't want to go over their allocated time out of respect for the women out in the waiting room. They were also very conscious of the care provider's time. So it was this internalised understanding that I have been given 20 minutes
Catherine:
[21:18] and I really shouldn't take up more than my allocated time. But when they did push for more time, they got it, but they were still holding back a little bit.
Mel:
[21:28] It's not a full conversation, is it, when you can't really explore the ideas? And for women who are listening to this having not yet experienced maternity care, There are some care providers who can offer you an hour or more of antenatal appointment in which time they'll be able to focus on your questions and help you kind of fill your birth back with answers. Whereas if you're going through kind of standard care, particularly here in Australia, it's not typical to have your own care provider who understands you fully.
Mel:
[22:02] You might have only 20 minutes or again, a private obstetrician, you could have even less depending that there are some beautifully holistic and communicative obstetricians who desperately want to understand their clients' needs, but there's a collection who aren't wired that way. And I mean, in that 20 minutes, you're having your blood pressure checked and all your physical checks and they're checking blood results and giving referrals for all kinds of things. So in terms of conversation time, you might get four to six minutes in which to kind of ask your most important questions. And I think you're right. Clinicians feel pressured. They're like, I can't give you a full explanation to three questions in six minutes. So, and I love that way that you described it is that the birth map is half the bridge. It's not the full thing. Really what completes it is a care provider and a place of birth that's going to honour that process.
Catherine:
[22:59] Yeah, absolutely. So in the thesis, one of the most brilliant things about coming
Catherine:
[23:05] up with an answer is that you can put it in pictorial form. And there is one picture that summarizes the entire thesis, and it's a picture of the Sydney Harbour Bridge, which was built from each side of the harbour. And the Sydney Harbour Bridge was also important to me because my grandmother was one of the very first people to walk across the Sydney Harbour Bridge. She was born in 1922 and watched that bridge be built and in 1932 when it opened she was in the crowd 10 years old walking across that bridge and so it's always been significant to me in my maternal lineage. So when it became apparent that, you know, we have to have two ends. It was so obvious, the Harbour Bridge. So on the Harbour Bridge, we've got.
Catherine:
[23:57] The road that you know where we've got movements going in both directions and so the road is a really good analogy for that informed part of the process where we need to understand what the care provider can offer us what is their skill set do they have the skills that I'm looking for and for most women in the study they started off with I want to have minimal or no intervention, I want to have continuity of care. But when they referred to continuity of care, they meant relationship. I want to have a relationship with my care provider. I want them to understand me, but I also want to understand them. I want them to see me as human and I want to see them as human. Is that really too much to expect? So, in that process, you've got the informed part is coming on the traffic deck, so where the traffic moves. But that traffic deck can't exist without the arch of the bridge. And that arch is the support. That is where the relationship sits. I understand you, you understand me, and we're in this together. We're holding it up. And the pillars on the end represent that confidence.
Catherine:
[25:19] So we've got the confidence of the women, and I found a really wonderful graphic to demonstrate how women make decisions. And it shows the held-up fist with the palm facing out, which is sort of that solidarity. You know, we're in this together. You know, we've got this. Holding on to the scales. And for women, they are making decisions based on who they are, the things they can't change, their values, the thing that makes them who they are. And they're balancing information and circumstances in that scale. So as information comes in, and it might be physiological information or it might be logistical information, such as this facility can't offer me a breech vaginal birth. So what are my alternatives?
Catherine:
[26:07] I have to travel three hours to get to a clinician that can support me. So now I have to weigh that up. Do I have the funds to pay for the accommodation that I need to pay for to go to that new facility? And then how do I get back? Who's coming with me? How long do I have to be away for? So there's a certain amount of privilege involved in being able to do that. So she may have to then weigh that up and say logistically that's not possible. So how do I make the best possible birth out of.
Catherine:
[26:39] What's now available for me you know making um making a difficult scenario better to be able to say okay i can't change that scenario so how do i make it mine how do i own it so from trauma to acceptance yeah and so as as you put that whole bridge together all of those elements are needed to to have this processed work and so what i found was that the book resourced women to build their half of the bridge but we need to also resource the clinicians to be able to build their half and that can be as simple as respect-based training which includes understanding what the birth mapping process looks like and the three tenets of that birth map is the support that is the relationship, the information which is that sense-making process where she comes to understand why certain options may no longer be available, what's my next best choice,
Catherine:
[27:36] and then that confidence in decision. And this is where I'm also challenging the language of shared decision making to make it supported maternal decision making so that there's no doubt who the decision maker is in this process.
Mel:
[27:52] So what you're talking about, because this is the language that is seeping into healthcare policies is this idea of shared decision-making where the woman and her care provider have a discussion and together with their knowledges combined, share the process of decision-making. But that really does give a 50-50 weight to the woman's decisions and the care provider's decisions. Really, it should be the woman making a decision with the information that she's been gathered herself or that she's garnered from her care provider. And that care provider isn't gatekeeping the information because this is the other thing that happens is, okay, well, I'm only going to tell you the things that I want you to know in order for you to make the decision I want you to make. It's this relationship where the care provider goes, look, I actually am not personally invested in the decision you make. I'm here to facilitate whatever decision you make and give you as much information as I have so that when you make your decision, it's not a reluctant yes. It's a like, do you know what? With all this information, I've decided this is what is actually best. It's not my first choice. I'm really disappointed I had to make this choice, but the thing I'm choosing is this option.
Catherine:
[29:13] There's actually a paper that talks about shared decision-making as there is a problem with the term shared decision-making because it suggests that the decision is shared. Hey, it's working for us. So let's not change it yet. You know, that's the quiet voice. You're not supposed to say that out loud.
Mel:
[29:31] You're also not supposed to. Yes, but I mean, I also have an issue with the language of woman-centered care peppered through all of the policies because in reality, although the policies say woman-centered care, this is not what is provided.
Mel:
[29:47] And here's where I want to ask about. Women can do birth mapping to build their side of the bridge, part of their bridge. And although there's a restriction on options for who's going to be at the other side building their side, a lot of women don't have access to sort of ideal birthing models. But now that women realise that a birth map and being informed is part of the future, perhaps this is an opportunity to optimise the use of the birth map. What can women do to possibly access a care provider who's going to match that expectation?
Catherine:
[30:24] That is like the ultimate question because less than 10% of women have access to the kind of care that they actually describe that they want. But most women don't realize that there are actually different models of care. When you go to the GP to have your pregnancy confirmed, so permission to be pregnant kind of thing, that GP is the first potential gatekeeper that you come across. So if the GP is not aware of or doesn't approve of certain models of care, the question might be, do you have private health cover? If the answer is no, here's your referral to the nearest public hospital. If it's yes, here's your referral to a private obstetrician. And you're, as a first-time mum, assuming that you're being offered the best options and there's an assumption and not an unreasonable assumption that you are going to be receiving personalised care in that system. I remember as a first-time mum, even though I wasn't in a dedicated midwife program, It was a midwifery-led program. So during the course of my pregnancy, I met most of the midwives at the hospital so that by the time I arrived in labor, they were all familiar faces. But the assumption I made was that I would be allocated a midwife on the day and she would be with me uninterrupted for the whole journey.
Catherine:
[31:52] And that's just not the case. In a bigger hospital, she may have had three other women that she had to hop between. And you have to be somewhat self-sufficient. You actually have to take responsibility for your birth. You have to hold onto it in complete ownership of whatever is going to happen because it is your journey. And a good care provider, like you just described, can sit there, this is not mine to hold, I'm here to support and facilitate,
Catherine:
[32:26] I have knowledge to share, I can absolutely be the Sherpa on this journey. But you actually have to make those steps yourself, you have to go through this transition yourself. And on the other side, that care provider is not making that full journey with you and you've got this new life in your arms and you actually have to get on with the job. So you need to be able to resource yourself.
Catherine:
[32:55] And the support people around you so with the birth map I really emphasize the involvement of your support people but it's not always the father it might be a female partner it might be your mother your auntie your sister but it's somebody who's going to stay with you for the duration of your mothering journey they're the person you can call in the night and say help they're the one that might be making you a meal bringing bringing you around and they might be the one that says that's enough visitors for today, everybody leave. These are the people that need to be your voice so that you can actually descend into your soul when you're in labour, that birthing zone that we talk about, labour land. But that labour land needs to sort of sit in that fourth trimester as well. We don't think of that early stage of mothering as still really part of that birth experience. We're still journeying together as a connected being with our baby. Babies are not meant to be passed around and away from their mother. They need to be close. This is something that mothers innately feel, like they do want their babies close to them. But the rules around us in that early motherhood.
Catherine:
[34:15] They often say, you know, the baby should sleep over here, the baby should do this, the baby should do that. And if your baby's not following the rule book, it's like, oh, my gosh, what am I doing wrong?
Catherine:
[34:25] So in the book, The Birth Map, it's got these questions to ask your care provider. It describes what decision-making is, but it also has a section about beyond the birth. And in the study, that section was Chapter 3 in the book. It was chapter three because it goes, think about what's going to happen, plan for what's going to happen, and then after the baby comes, here's the next bit. And the feedback from the study was that the women were going through the book in order, and then they go, oh, beyond the birth, awesome, I'll deal with that on the other side.
Catherine:
[35:02] And they said, oh, I really wish I'd read that chapter in advance. There's nothing about the book that is deeply detailed. It doesn't it's it's mostly questions it's question prompts so that the woman can determine, where she wants more information so that she can see herself in that story what are my values what are my needs what's my circumstances and these are some questions that can help you figure out what you don't know so you can move forward so the birth beyond the birth section to looks at what to expect in the early days, what kind of behaviours, what do you need, how many onesies is practical. Some of those really practical logistical questions talks about having a gathering of women. In the book, I've neutralised things and we just call it a gathering of supporters. So what do you need to do to bring your team together, So that village that we talk about in the afterworld of after you become a mother, life before children, life after children, what does that look like?
Catherine:
[36:12] So one of the biggest changes I've done with the book post-study is chapter three is now chapter one. We start with beyond the birth. Where are we going? Because we discover so much about who we are when we start to consider what's coming on the other side of this birth. And that's a process called coherence. It's about creating this sense of self, who I am, where I'm going, what support do I have, And what is my reality on the other side? Because so much of that will impact many of the choices that can be made during the pregnancy and then that labour as it unfolds. That idea of starting where the destination is, how can you possibly build a
Catherine:
[36:57] map if you don't even know where you're going?
Mel:
[37:00] What is great about this is that you allowed the research to manipulate the map. And this is what makes the birth map a more evidence-based way of mapping and planning your birth is that it's been tested, the feedback has been received, there's been alterations made to make it better than it was. And as you were talking, I was just thinking, gosh, do we need to change it from the birth map to the matrescence map?
Catherine:
[37:30] Oh, wouldn't that be lovely?
Mel:
[37:32] And the point I want to bring us back to you for a second is is this moment at the GP when you're given permission to be pregnant. I think this is like the pivotal, one of the moments in the birth map where you could go this way, this way or this way and as you rightly said, women aren't given the full menu of what's even available to them in their area. They're given the menu of what the GPs manage to garner from their own education and experience and if they're not particularly interested in midwifery models of care or they don't understand the services around them like the opportunity maybe your hospital has a free continuity of care program where you can get your own midwife or maybe they even have a home birth program that perhaps the GP didn't even think to mention because they don't believe in home birth I mean I've had clients who went to their GP before when we used to have to get referrals
Mel:
[38:28] And the GP said, I don't believe in midwives. I'm not going to send you to a midwife. So immediately just even knowing that this person who you've gone to to give you guidance as to next steps is possibly only offering you the information that they know or that they support and so you mentioned about women taking responsibility. You know, do a quick Google. What services are available around you that you could choose and immediately start yourself on a different path in your map. And we will get to the rest of your findings. But early in the piece in your paper, you talk about power balances in maternity care and that a power balance is pivotal to how your preparation for birth is going to pan out. Can you talk to us about what you know of, like throughout your doula ring journey and all your education, what do you mean by a power imbalance in maternity care?
Catherine:
[39:29] It's a, I like the way Rhea Dempsey refers to it. She calls it the veil of acquiescence. And it is this mindset that comes over us when we step into the doctor's office. And this happens from before pregnancy. Any time we visit the doctor's office, we sit in the waiting room and we wait our turn and then we are invited into the doctor's space. We're a visitor in somebody else's space.
Catherine:
[40:00] So already manners dictate that we must put ourselves in a visitor's mindset, a subservient mindset. And this exists in a process that's called negative politeness. And we see that when women go into the maternity space, because it's an extended period of engagement with health care, it's much more pronounced in how it plays out. So you go into visit for your appointment. You are on somebody else's scheduled time. So already the power is with the authority is with the care provider.
Catherine:
[40:38] They get to determine the timing of when things happen, but also what happens at that particular time. And this also includes when information is delivered. So in a needs-to-know basis, you might not find out about the GBS test until the day that you're being handed the swab and told, today we're doing this test. And there's no time for discussion. That discussion doesn't generally happen. It's usually, oh, it's just a simple swab, you know, it's standard care, off you go. If that's a consent point and oftentimes in these interactions and this is where that power dynamic comes to play women don't realize that when they're being offered something that it's actually a consent point and the power actually lies with them to say yes no maybe what are my options they stay usually presented with that just hop up on the bed and we'll do this here's your swab here's your test here's your referral for your next sort of test and off you go and each one of those is a consent opportunity so that power dynamic is that it is presented to us as standard and the problem I have with consent is that it assumes the yes it's it's whether it's sexual consent or consent in health care that starting point of consent says there's an expectation that you will say yes.
Catherine:
[42:05] The no is dissent. The no is where the naughty girl sits. The no is where the rebel might sit. But if she's not saying no in confidence, often I find that the care providers will document that no if it's said confidently without question.
Catherine:
[42:24] But if that no is a nervous no because there's that underlying current that saying no is the naughty girl option, a care provider who hears that question is not going to be confident in that no. They're not going to document that no because now they've got that question of liability over their head. So that's where that policy sits for the care providers. They're nervous as well because the way that the system is structured, they're holding this responsibility. And so I think Spider-Man, I'm not sure who says it in Spider-Man, but I think they got it the wrong way around. It's not with great power comes great responsibility. With great responsibility comes great power. So the care providers have this perceived holding of the responsibility because this consent process is about relieving liability. It's about this idea that the liability sits with the care provider, except that consent means that you're the decision maker, which means that that decision is your responsibility. So in reality, we hold the responsibility ourselves, but we're not given the means to hold it. It's heavy. It's a lot to hold. So we tend to hand that responsibility over to the care provider really willingly. And in doing so, we hand the power over.
Catherine:
[43:51] And we can take that power back by saying, I'm actually going to take responsibility. But how do I do that? I need to know the questions to ask. I need an overview of where we're going to go. So that's why we need the bridge because the care providers need to be able to let go of some of that responsibility. Because they are feeling the weight of that potential liability as well.
Mel:
[44:15] What you're describing of a care provider who's willing to let go of responsibility, I think that takes experience and bravery and some rebellion on their part too because the system is really set up to make us assume that we have the upper hand in the power dynamic and that the consent process has become procedural and that the consent process has become procedural as an ask covering exercise whereas actually yeah as you said it allows the woman to take responsibility if she's not aware though and I love that you've mentioned the idea of the power balanced just being aware that there is this underlying power struggle between you the woman and your care provider means just by knowing that and you say okay when I come to a consent point or a decision point. I can choose to take responsibility and I can choose to hold onto the power and not give that over to my care provider. And then what you might find actually is you can set a precedent for the rest of your care, that your care provider goes, right, when this person walks through the door, I know she has set the standard of taking responsibility.
Mel:
[45:26] And I've had two clients who really stick out as really like clearly taking ownership which is great I mean most of my clients have because I'm a bit of a you know on the fringe kind of birth choice but there's been one client who actually sat in my chair instead of the chair allocated to women which I thought I love this and through the whole appointment she sat in my office chair and I sat on the bed that I have for women to use and like the the day bed um and then I had another client who used to walk in and kick off her shoes and lay down like sprawl out as if she was at on her own couch I love this because they just knew what they wanted how they were going to conduct themselves they took ownership of the space it was clear what the dynamic was in our relationship and they were just by small gestures saying, I own this experience. Have it be known there is a power dynamic that you can take responsibility for. So we spoke about communication and you mentioned the sense-making Because sense-making is one part of the findings, but what were your other findings from your paper?
Catherine:
[46:44] So the sense-making is the process of coming to understand what my options are. Then there was relationship, which came out of that sense of support that women were seeking. And when they spoke about wanting continuity of care, they didn't want to be repeating their story. They wanted to be seen and heard. They wanted to connect with their care provider. so that's why I very consciously use the word relationship because that's where humanity sits and whereas continuity of care is a very clinical term that also is subject to uh how do I put this diplomatically um.
Mel:
[47:25] Don't be diplomatic just say it
Catherine:
[47:28] Be a rebel yeah the um.
Catherine:
[47:33] It can be used against us as well.
Catherine:
[47:36] So when they're making these measurements of we've extended continuity of care, now more women have access to continuity of care, that continuity of care can look like nice handovers. So it's not the same care provider, but yeah, you're not having to repeat your story and we've got consistent policy across that particular process. And that's all very well if it's a woman-centered individualized care policy but if it's a restrictive policy then it's not really it can it's continuity of something not very great but it can also mean that I just simply saw the same care provider at each appointment but it doesn't necessarily mean that they were good appointments so as I found in the study with the private obstetric care that was a continuity of care model and the women very consciously chose it because it was a continuity of care model and they they understood or you know assume that that continuity of care not only are they going to be seeing the same care provider and building a relationship with them but that that care provider would be with them during the birth and they were all deeply disappointed that they were not attended by that care provider for the length of the labour.
Catherine:
[48:56] The care provider in the private obstetric model tends to come towards the end or pops in and out if they happen to be at the hospital at the time.
Catherine:
[49:06] They also found that it was all very well, except in the cases where that care provider was away and hadn't told them that I'm not going to be here at this time. So then they get to the hospital and their person's not there. And that was felt much harder than if they had had a conversation with the care provider that was very open and transparent. I'm going to be away at this time and I would like you to meet the backup obstetrician. And this is who you'll meet on the day. What they wanted in reality was a relationship, somewhere where there was an honest transfer of information, not just about the pregnancy, but about the logistics that sat around that pregnancy as well.
Catherine:
[49:54] Then the other key critical component, all the elements overlapped. None of them could be considered separately. The other element was that confident decision-making, which was what I now phrase as supported maternal decision-making because we need to know that a woman is the decision-maker. And throughout the thesis, I refer to the decision-maker as that role because that really elevates her power. She's not a patient anymore. She's not a consumer or a receiver of care. She is a decision maker in seeking care from a provider who has a skill set that she is seeking for that journey. So that change of mindset and using the phrase of decision instead of consent.
Catherine:
[50:43] So in that part of the finding when it came to the decision making was really consciously looking at any consent point as a decision opportunity that this is an opportunity for you to direct the next part of your journey but those decisions can't be considered in isolation and as the women talked about the the need for that sense making along with the relationship to make that confident decision what they needed was what will happen downstream what happens if If I say no, how will that change the options that are available to me in pregnancy and then in the labour?
Catherine:
[51:23] If I say yes, how does that change my options? So by saying yes to an induction, we know that that birth is going to look different now.
Catherine:
[51:32] It's no longer a physiological pathway but a medical pathway. So in the book, it breaks down the different birth journeys as your physiological pathway and post the study, the language has changed in that as well. So the book that was evaluated talked about a fast birth pathway compared to a vaginal birth pathway compared to a cesarean pathway. And so that was framed as fast expected contingency. So the assumption that a cesarean is always a contingency, but there are some women who would choose a cesarean as their first choice, not as a contingency. So that language was not quite working. So post the study, it's been very neutralized and it's physiological, medical for medical vaginal, and then the cesarean pathway. And there's no weight on those pathways. We're making the best decision based on the circumstances. But once we say yes to an intervention, we shift from that physiological pathway onto the medical pathway and you can't go back. So there are some options that are now closed to us as we move through those choices.
Catherine:
[52:47] Logistically not possible. So now what are the options that are still available to me? And the really critical decision point seems to be around the epidural zone. Yeah. So this might come up in the slower birth. So in the first version of the book, fast birth was a big kind of – and that was partly because my personal experience is I've got four babies and 10 hours of labour under my belt.
Mel:
[53:14] In total.
Catherine:
[53:16] Of four babies. Yeah. So it's like I don't really get labour. Like that scene out of Monty Python. Can somebody get that for me? And so fast birth was something that was really important to me to include in there. I also live in the country. So.
Catherine:
[53:35] Everybody I know has to travel at least an hour to get to a hospital to have a baby. And so it's really important to have a preparation for what do I do if this is a birth before arrival. Birth before arrival as a country woman is, it is remiss to not have a preparation for that. And for some women, when they're weighing that up in their own circumstances, that means I do want an induction because I do not want to risk that birth on the side of the road. But for other women like me, it was, okay, I get it. I can just get on with that. And I was comfortable in the, if I have to do this on my own, I can. Mainly because, and it was a good thing that I did, because baby number three was a silent first stage. And we pretty much skipped to the, oh, that's coming out, right? That's not a poo. um and ta-da you know there's a baby yeah so for me the fast birth pathway was a really important inclusion but post the study there is now a slow birth pathway and this is the pathway that's really the most critical where the mapping really comes into play we are going to map out pathways 90 of them we will not use we will not journey on 90 of the pathways we map out.
Catherine:
[54:55] But we are going to be really grateful for whichever one we mapped out because we are now able to know where I am in that journey and what my options are beyond that point. So the slow birth pathway where the epidural can sit, that can be a really critical decision point for many women. An epidural might be an opportunity to rest.
Catherine:
[55:17] And we might still go on to have a vaginal birth. But the epidural turning point may also be the point where a woman says, I'm calling it and I actually want that cesarean and she can ask for it. And that's like a mind-blowing alternative to be able to say, now that these interventions, they're not just about a doctor making a recommendation.
Catherine:
[55:41] But if I understand what my options are at that critical point, I can say I'm ready for a cesarean now because I'm not open to the pathway of potentially the forceps delivery that might come after an epidural long. I'm now tired. Baby's getting tired. It might become quite urgent and then I no longer have the option of a cesarean because the baby has descended so far and now things are happening really quickly. The outcomes of a forceps delivery vaginal birth, when she's weighing it up in her own decision-making, the caesarean might not feel like the worst option when she's looking at that particular detour point. And that might come from someone who has had a previous fourth degree tear, or it might come from someone who's had a previous emergency caesarean. And this time they want to call a caesarean before it becomes an emergency. Only the woman on that journey can make that decision but she can't make that decision if she doesn't know what the different pathways might look like for her.
Mel:
[56:50] So engaging with the birth map is about Going on those pathways ahead of time, and in my PhD, I called it preparing for all possibilities. So my PhD, you know, the women who were planning a free birth, they talked about all the possibilities that could occur in their preparation. And this whole chapter about preparing for all possibilities meant that, okay, if this should happen, here's the plan. Here's what I've got. If this should happen, here's the plan. my bag's packed for postpartum transfer I'm booked into this hospital my husband's got the phone number we've got somebody to look after the children if I need to go you know we've worked out a way to measure blood loss if I need to hey we also took a resuscitation course because I want to know that I can resuscitate my own baby if I need to you know this is not a unique it's not a unique journey to be planning for all possibilities and that's what the map sounds like. For women who even say, look, I don't want to have cesareans, I'm not even looking into it. It's kind of, oh, you might want to because there might be a moment where a cesarean becomes the best possible scenario and you need to know if you want a general anaesthetic or a spinal anaesthetic. Do you know anything about those?
Catherine:
[58:09] They're like, oh, I don't.
Mel:
[58:10] I don't want to be making that decision after a long labour. So I think what you're describing is is for women to explore the possibilities before they have to make decisions so that when and if they're in a scenario where things have to change, they can confidently say, look, I've thought about this scenario and as I thought about that scenario, this sounds better to me than that option. And so that's what I'm going to decide.
Catherine:
[58:38] Yeah, absolutely. And that's where the game of birth comes in.
Mel:
[58:42] Tell us about the game because there's a book and then there's a game.
Catherine:
[58:48] I'm such a nerd but it is it is based on a choose your own adventure process and I used the mother baby report statistics to develop the game so that every roll of the dice which is the bits we can't control sets up a scenario and then gives us the choices that we would have in that scenario and it allows us to sit hypothetically in different scenarios, but because it's statistically based, it means that what happens next will start to become channeled towards where those statistics lie. So once an intervention occurs, the likelihood of things becoming more intervened with increases. Use a 20-sided dice. So anything up to 5% comes into those statistics. So anything that's got at least to 5% chance of happening.
Catherine:
[59:42] Can roll up in those statistics. And it can put us in a difficult situation, but because it's hypothetical, it's safe. And we can say, hey, yeah, what would we do in this scenario? You know, this one's really tricky. And then they can go to their care provider and say, what would this look like in this particular facility? And that might be the answer is, if that happened, we actually need to transfer you and you would go to this hospital. And so the logistics around that then become, well, how do we get to that hospital? How do we get home from that hospital? How does that change? What if mum is in one hospital and baby has to go to another? How can we manage that scenario?
Catherine:
[1:00:25] And if breastfeeding is important to a mother, how does the birth then impact the breastfeeding journey? So how can we then continue this mapping out of possibility? And for me, It was still not called a MAP yet, but it was this multi-pathway birth plan when I was pregnant with number three. And my worst case scenario, and it happened to be on the day that the student midwife was sitting in on the appointment. And my worst case scenario, the labor has got to a point where I now need an emergency cesarean under general anesthetic. It's life-saving. Horrible circumstances have happened. Baby's gone to NICU. And I mean a coma.
Mel:
[1:01:10] He's like, right?
Catherine:
[1:01:12] I'm like, I'm not actually afraid of this scenario, but I'm being really thorough. So the first thing that happens is that gentle dismissive, oh, if that happens, that's what we're here for. And I said, but if that happens logistically, there are several things I need my husband to be prepared for, because it is absolutely critical that I'm able to breastfeed on the other side of this I can handle that an emergency might happen but if I can't breastfeed on the other side someone's going to have to answer for that and really cranky about and I think very upset and so what I wanted for that was that who was going to be in the room I was in a mid a continuity of midwifery program so I had an allocated midwife and I was going to go through the birth center. So what would happen? She said, well, obviously we'd be moving from the birth center into this part of the hospital, but I would travel with you. Excellent. So you're able to advocate for me in this scenario. Well, this is what I want to have happen. Can the baby, let's assume the baby as well, can the baby be put on my bare chest and do the breast crawl? Is that something that can be facilitated? And she's like, well, yeah, we could. Yeah, we could facilitate that.
Catherine:
[1:02:33] Awesome okay if the baby's not well I would like you to express my milk and or show my husband how to do it ideally like I'd prefer it if he was doing the touching or my midwife but please get my colostrum and give my colostrum to the baby using non-bottle methods she said yeah we could yeah we could facilitate that absolutely and I said okay I've never been able to express a drop in my life. I've breastfed all my babies, but never would my body release the milk unless the baby was there. So I was really hoping that the coma would really help in that situation.
Mel:
[1:03:14] If I take my mind out of the scenario, maybe my body would just give the milk out.
Catherine:
[1:03:20] But if that doesn't happen, my friend is going to come in and this woman could, you know, she produced enough milk. She could have fed the whole country and she was absolutely like, Yes, Catherine, I'm there for you if you need me. So I said, my mate is going to come in and feed the baby. And that's where I got a hard no. And I went, okay, well, in that case, I'm going to bring in some of her milk. And they're like, look... Any milk that comes in, as long as it's got your name on it, no questions will be asked. Because I already had children, the chances of having a stash of milk, I'm like, cool, we're going to be bringing in some milk and I would rather use that before we go to formula. So that's the World Health Organization, five steps, first from the mother directly, then from the mother expressed, then from another woman directly, then from another woman expressed, and then formula. World Health Organization guidelines. But not standard practice in the hospital. And because in this situation, I'm not coherent. I'm not able to advocate for myself. So in that situation, what was just a birth plan, but my instructions within this birth map as it became were like an advanced care directive. It had been discussed.
Catherine:
[1:04:39] I had given permission for my body to be touched for the expression of milk for the baby in that circumstance. I had expressed my needs. And even though it wasn't standard practice, it could then be facilitated. I shared that in a mother's group. You know how on Facebook they had the Jew groups? In the mother's group, I shared, hey, I just had this awesome discussion with my midwife about how important it is for me to breastfeed on the other side. And I gave permission for this to happen if this really bad scenario occurred. It made another woman in the group say, you've just made me realize I have to tell my midwife about my sexual trauma. Anybody did that to me when I was unconscious, I would be ropeable.
Catherine:
[1:05:23] And so it's the same decision-making process, but those different values, those different circumstances, the personal logistics that come into play, a different decision is made. Both of those decisions are valid and correct. There's no one way.
Mel:
[1:05:43] And I imagine that, let's hypothetically say that scenario did play out, and you woke up and someone said, hey, here's what we did, and it matched every one of the points and decisions that you had made, I imagine that you would have a sigh of relief and go, great, thank you. My care was great, even though I had a caesarean. And was in a coma and the worst possible scenario played out in a clinical sense, that's still a great outcome in a way where you go,
Catherine:
[1:06:18] It's the difference between trauma and acceptance.
Mel:
[1:06:21] Exactly. I planned for this. I knew this was a possibility. But in this scenario, we made the best out of it. My baby still got colostrum. Everybody did exactly as I asked. Like this is the type of care that women could look back and go, oh, wasn't that great? We've been talking for some time. I'm aware that we could keep going. But is there anything else that you think there's just this whole other thing that I have not yet explored from your research that we could kind of?
Catherine:
[1:06:54] Wrap up with i think we've covered everything in the research but the the potential this research has and the potential that the book and the game has now for health care i this is my vision yes now this if i was in charge of the world this would be happening now uh my vision is that those mother baby report statistics will start to mirror the decision points in the map imagine if we started collecting the statistics in a way that was actually meaningful to women rather than measuring economic decision making or however these statistics are used but how can those statistics be meaningful to women it would also make the game much easier to update but my vision is also that every woman in Australia will have access to this book in some format at the moment it's only available in English. That will change. It's also only available in this sort of book format, which doesn't appeal to everybody. So audio options would be great. I've created a prototype of an opportunity that takes the book and the game and puts them together online.
Catherine:
[1:08:14] And this prototype is available in my member area, which is free to access. The reason it's in a member area is because I'm collecting data, as all good scientists does, of where the people are who are accessing this resource. So I don't need you to give me all your personal details, but please give me your postcode. Because that is what I can then use when I'm talking to local health districts to say these are the number of women that are accessing it in your area. And that came up in the Tasmanian birth trauma inquiry. They were really interested to see what my web statistics were about accessibility and I was able to break that down based on location because of that. So that was, yay science.
Catherine:
[1:09:03] Data is data is what helps drive the change we need in policy now that the birth map is evidence-based it's validated it gives us the tool to be able to advocate for women's voices in maternity care but the findings have also allowed us to see where the limitations are for care providers what do we need to do to support care providers to build their half of the bridge so that we can have truly effective communication within maternity services which is the absolute crux of humanity matrescence is happening we are not just processing women to get babies out we are transforming women on their journeys we are creating families this is the core of humanity let's get it right your.
Mel:
[1:09:52] Work is cut out for you i cannot see a point at which you'll be finished because I just think once you solve one problem, you will move on to the next one and
Mel:
[1:10:02] I'm so grateful for that. So I just want to implore if you're listening. Catherine's made, you know, to a fault things so accessible and free, you know, but I do recommend that you purchase the birth map instead of just flicking through the free version. But I think if you do have a look at it, it will make sense of a lot. I'm a visual learner as well. I kind of need to see what is she talking about. But I will put all the links in the show notes so that you can find Catherine's work. You can read her papers, have a look at the birth map, explore the game, which I can also see is a great opportunity to discuss this with the other parent of the baby, even if they're not going to participate in reading the birth map and doing all that kind of mental gymnastics that happens from that level. Thank you so much for sharing all the work that you've done. And Dr.
Catherine:
[1:10:55] Catherine Bell. Whoa. Yeah. Thank you for the opportunity to share it. Now this is brilliant.
Mel:
[1:11:02] Well, that has been today's episode of the Great Birth Rebellion podcast. You will find all the resources in the show notes and in the resource folder if you're on the mailing list. This has been Birth Mapping with Dr. Catherine Bell. I'll see you in the next episode of the Great Birth Rebellion. To get access to the resources for each podcast episode, join the mailing list at melanithemidwife.com. And to support the work of this podcast, wear the rebellion in the form of clothing and other merch at thegreatbirthrebellion.com. Follow me, Mel, @MelanietheMidwife on socials and the show @TheGreatBirthRebellion. All the details are in the show notes.
This transcript was produced by ai technology and may contain errors.
©2025 Melanie The Midwife
