Episode 116 - Acupuncture and Acupressure
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. Welcome everybody to today's episode of The Great Birth Rebellion.
Today I have two guests to discuss acupuncture and acupressure through various stages of pregnancy and labor and birth. We've got Dr. Kate Leavitt who is an acupuncturist, researcher, educator and maternal health research specialist focusing on childbirth education practices. She's a senior research fellow at the University of Notre Dame in Australia, Sydney School of Medicine, and an adjunct fellow at the NICM Health Research Institute at Western Sydney University, and an honorary fellow at the Collaboration for Midwifery, Child and Family Health at the University of Technology. My goodness, Kate, you're a busy woman.
Mel:
[1:12] And Kate has a ministerial appointment as a practitioner member to the Chinese Medicine Council of New South Wales. She has over 20 years of experience in clinical trials, public health research and epidemiology, training in education and in clinical private practice. Insane. And I'm also going to introduce Heidi Williams, our other guest, who's a privately practicing endorsed midwife, just like me, on the central coast in New South Wales here in Australia. She's completed a Master of Midwifery in Acupuncture Research and is currently doing a PhD at Edith Cowan University looking at the acceptability, feasibility and experiences of acuneedling, so where a midwife administers acupuncture, for posterior deflexed or asynclitic babies during labour and birth. So that just means if the baby's facing in a posterior instead of an anterior position and if the head's not quite in the right spot, she's doing a study looking at the impact of accuneedling administered by midwives on that. Heidi is also a casual academic at the University of Newcastle and along with Kate, runs courses in accuneedling for midwives and other health professionals.
Mel:
[2:28] Welcome, you incredibly busy and skilled women. Thank you for being here.
Kate:
[2:36] Thank you so much for having us.
Heidi:
[2:38] Thanks, Mel, for having us.
Mel:
[2:40] You're very welcome. Dr. Kate Levitt. Amazing. Beautiful. I want to give each of you an opportunity to introduce yourselves as well. So, Kate, I might ask you to kick off and give us a bit of an introduction to yourself.
Kate:
[2:57] Thanks, Mel. Well, mainly I'm a researcher most of the time and also an acupuncturist some of the time. And I do really love the intersection of research practice in women's health, which I am mainly at the University of Notre Dame in the School of Medicine there. And I feel like it's a really fantastic opportunity to be able to look at where there are issues around women's health, particularly in labour and birth, and using the other half of my skills in the acupuncture, and I'm also originally trained as a teacher, so my education skills about how we can put that into things like antenatal education programs or training for health professionals or other ways that we can look at implementing acupressure, acupuncture, Chinese medicine skills for labour, birth, women's health, all of those things. It really just lights my fire a lot to talk about and do research around women's health and how we can improve the health and wellbeing of women in general
Kate:
[4:07] By sort of the framework around Chinese medicine, which is largely preventative and not fixing things when they've gone wrong. So that's kind of what I love. And I've got three daughters of my own and have found it to just be incredibly a beautiful and useful tool and for everything in my life.
Kate:
[4:28] So I love Chinese medicine and all its applications.
Mel:
[4:31] And how about you, Heidi?
Heidi:
[4:34] Thanks, Mel. Well, I am extremely passionate about acupuncture, acuneedling, acupressure. I fell pregnant after seven years of trying from an acupuncturist. I was told I needed an egg donor and I was pregnant three weeks later, naturally. So after that I had acupuncture to hold the baby and all through pregnancy and I had pre-birth and labor activation at 40 weeks I went into labor within 48 hours and had a really quick labor and a great breastfeeding journey and postnatal experience and I thought all women should have access to this. And I brought it over from New Zealand. Debra Betts came over and we ran the course over here that she teaches over there. And it's just gone from there. And I'm just so excited that we can potentially have midwives offering this to women in every birth setting.
Mel:
[5:42] Do you think that it's entirely possible to train midwives in the skill of acupuncture as far as they need it in their role?
Heidi:
[5:51] Yes, because acune needling is prescriptive. So it's certain conditions, certain points only. We're not diagnosing, we're just supporting women to stimulate The energy in their body that can help conditions, you know, so like posterior babies, nausea and vomiting, it can potentially reduce the feelings of nausea in labour and birth or pregnancy.
Mel:
[6:17] Sure. So you're kind of giving, rather than an actual trained acupuncturist who's capable of diagnosing and working with the intricacies, midwives could apply some basic formulas to some basic scenarios and get some benefit from that acu-needling.
Heidi:
[6:37] Exactly.
Kate:
[6:38] Great. I think that we've got a unique position in our healthcare system where in an extended scope of practice, midwives can use needling to affect a great change or a great benefit for women in labour and birth. Ideally, our system would incorporate acupuncturists who are trained and registered to oversee and to facilitate and to train and to keep that going within a hospital system. As it stands at the moment, acupuncturists see women outside of the hospital system. There's a lot to be said in the training to be able to diagnose, do pulses, abdominal diagnosis, like the full range and scope of traditional Chinese medicine or Japanese medicine, whatever it is that people are using, but the full scope of that. However, within the context of a hospital birth or even a home birth where it's midwifery-led, we are really in a unique position where we can utilise the skills both in midwifery and capacity for needling to be able to make a great deal of change. But I also would love for acupuncturists to be in the hospitals. But midwives are incredibly skilled and incredibly good at this when we train them. They've got a basic level of skill that really lends itself to the whole practice.
Mel:
[7:59] Well, not only that, but they're actually in the birth space. It's, you know, you can take, you know, it's not like we have to call anybody in. We've got the benefit of being there. And midwives have trained in all kinds of things, you know, reflexology and spinning babies and, you know, all kinds of strategies that we can apply to assist a woman in labour. So if you're saying that, yeah, there's definitely some kind of tried and tested formulas that we could apply, why not?
Heidi:
[8:33] And we also know how to palpate and we also know how to needle because we're trained in our undergraduate degree on how to do that. So this is just advancing that skill with some traditional Chinese medicine techniques.
Kate:
[8:51] But it's a magic combination of training and skills there with midwives.
Mel:
[8:55] And, you know, traditionally trained community midwives –, would have had a whole collection of skills and medicines and herbs and all kinds of things that they would have applied in the birth space. We've really reduced the work of midwives in a Western setting to being very clinical and very physically based. But this sounds like it's calling for a reintroduction of all of that wisdom that midwives used to have that they could apply to women's birth. So, I mean, I'm all for it, especially if it has the benefits that we're going
Mel:
[9:31] to talk about, then why not? First, there are potentially people coming to this podcast wondering what acupuncture and acupressure is. Well, let's start with acupuncture and the philosophical background behind acupuncture. What is it and how does it work?
Kate:
[9:50] All right. Yeah, look, great question. And I know a lot of people, we assume that people know what acupuncture and acupressure is, but maybe it's not always that clear. There's a little bit of mystery around it still, I think. So it's originated in China about 4,000 years ago, and acupuncture is just one of the modalities within Chinese medicine or East Asian medicine. We've seen back centuries ago, the spread of the Asian medicine through Japan, Tibet, Korea, India, a lot of those countries. So we kind of refer to it as East Asian medicine in its totality. In Australia, they teach traditional Chinese medicine, as in lots of Western countries, that's the standard. When I did my training, we did classical Chinese medicine, and I also studied in Japanese acupuncture. So there's a variety of different methods there. But as I think of it, there's different ways to do it. But essentially, it's the same kind of idea behind it. So acupuncture is probably the most well-known of Chinese medicine modalities, and it's where you use very fine needles, which penetrate the skin along the body. And along the body where these acupoints are, there's one of 12 to 14 meridians or pathways around the body. And each of those pathways kind of corresponds to an organ system, like the spleen or the liver or the kidneys.
Kate:
[11:18] But it's not as in a real spleen or real liver, it's the function. So what's the function of the liver within Chinese medicine? So the liver might be around moving blood and bringing hormones, and it's about your active energy, and it's about expansion. When a liver is in expansion, you know, a liver person is in expansion, they're leaders, they're greats like big forests where they can really bring a whole lot of big ideas, big pictures. When a liver is in contraction or stifled, there's irritation, frustration. So it's kind of like the function of an organ system. And these energy meridians or pathways correspond to that.
Kate:
[12:02] You see the energy flow as in qi and blood. So qi is like your energy, your vital force, all of those things. And blood is all fluids in the body. Qi leads, blood follows. So when you've got someone who's got good energy and flow, their blood and hormones will flow normally and naturally as well. All these kind of words, qi, blood, yin, yang, it all corresponds to Western structures and functions. It's just that the language was developed in a very different time and a very different place. And so people have got a little bit of a bias around it, but it's corresponding and translatable to Western ideas. And it's things like blood vessels, the nervous system, the fascia, muscle chains. They just originated from a different system of medicine and with a different understanding about our relationship to the environment. So in Chinese medicine, there's a big emphasis on relationship to environment and how the organs and person responds to that.
Mel:
[12:58] So Kate, are you saying the words that were used to describe how acupuncture works just sound a little bit woo-woo because it was before they really had a deep understanding of how the body was made up. So today we would call it fascia and nerves and blood vessels and whatever else we've got in there, but they were just putting different words to the same physical anatomy that we understand today.
Kate:
[13:26] In one respect, yes, but in another respect, it's also another language. So if you'd say energy in English, they'd say qi in Chinese, but it doesn't mean it's woo-woo, it's just a different language. And it's words that we've adopted. It's like also when I hear people using traditional words to describe concepts that we don't quite have. Energy doesn't quite do it justice. Qi is more than just energy. So it's a bigger concept and it originated in a different place. So there's a bit of both. It's just that it's in another language, but also it's concepts that we don't quite get in a narrow Western mindset. In terms of medicalization, Western concepts are reasonably narrow compared to Chinese medicine concepts. You know, Western medicine is fantastic at acute emergency situations.
Kate:
[14:13] In my mind, Chinese medicine is good at the chronic, big-picture relationship with environment and illness and disease, those sorts of preventative-type strategies. So in Chinese medicine, the qi is more than the life force, and it's sort of all of the energy that you can imagine. And the function and substance of blood and qi, when it's blocked, creates an imbalance. And that's what we see pain eventually leading to disease or dysfunction so it's looking to create balance within the body balance both the organs as well as the physical structure so if a pelvis is imbalanced we look at where like a physio or someone might look at you know where's the pelvis got an imbalance is there something in the in the hip flexor is it in the SI joint Is it in the hip, you know, and looking for where that imbalance comes from. And it could have started in the shoulder, commonly left shoulders, right hips or something. You know, it's looking at the way the body works together. And because Chinese medicine also loves an agricultural analogy, we love that.
Kate:
[15:22] We think about like the energy pathways or meridians like these agricultural ditches that carry water to the fields. and sometimes they overflow and then we've got times of flooding that we need to do something about that. And sometimes there's not enough water and we've got some dehydration and therefore the fields don't flourish. So there's lots of agricultural analogies throughout Chinese medicine which does bring to mind what's happening within the body. So in the West,
Kate:
[15:49] we kind of associate meridians maybe with planes of fascia or nervous systems. Connective tissue lubricates and supports the body. It's highly responsive to the stimulation with needles as well. Under imaging techniques, you can see when the needle's inserted, the fascia line up differently around the needle and the certain cell receptors also respond, which increases hormonal release, as well as nervous system responses. So you're seeing on the level of the fascia, the cells, and on the nervous system, as well as responses by the brain and neurohormonal activation. So the imaging techniques, as they get better, we understand Chinese medicine affects more and more.
Mel:
[16:30] So they've actually done, are you saying MRI studies to map the impact of needling and they can see a physical response to putting a needle in.
Kate:
[16:40] In the brain, in the body, you can see the responses throughout the system.
Mel:
[16:47] Yeah, amazing.
Kate:
[16:48] And also depth of pressure as well. So depth of needling, depth of pressure, that actually makes a difference. That's a real emerging kind of evidence space now about if we're doing shallow versus deep needling, if we're doing light versus moderate or deep pressure with acupressure, we're beginning to see the differences what different cell systems or nervous systems or fascial systems are activated by the pressures or depths of those needling or acupressure. So that's a really kind of exciting little look now at how those different techniques and modalities can be used in different environments to affect different kinds of changes.
Mel:
[17:31] Yeah, amazing. I mean, I'm an advocate and a user of acupuncture, mostly because I have seen it work for myself, but I wasn't sure, you know, in Western cultures, we have an expectation of what evidence looks like in terms of does this stuff work?
Mel:
[17:49] I can feel that it works for me. And it sounds like what you're saying is there's quite a sound evidence base to indicate that it's a really beneficial modality.
Kate:
[18:00] Absolutely. And on top of that, there's more evidence for acupuncture than there is for physiotherapy. And 10 years ago, there was more evidence than nursing. So we have to account for the fact that there's a bias in our understanding of the medicine as well. And that while we think we understand the Western concept of physiotherapy, and it's well embedded into our hospital systems and also outside of hospital, we actually have much more evidence for acupuncture and yet it's not embedded.
Mel:
[18:33] Well, and it's interesting that you say that because in preparation for our, conversation, I was doing a deep dive into some of the research around acupuncture and I was very impressed with the number of people who they, you know, the number of subjects that have been used in acupuncture studies and it struck me, you know, we recently spoke to Dr. Kirsten Small about the research around CTG for example and even just as I looked at the number of people that they've used if we look at that even just that small element of the number of people that have been in the studies, compared to the number of women that have been studied for CTG, CTG doesn't seem to have had actually as much research as acupuncture has yet we use that almost for every single woman in every single pregnancy and then we're stating that there's doubts around the efficacy and acupuncture.
Kate:
[19:24] And I just, you know, invite you to look at the demographics of those people who are in positions of power in funding bodies, NHMRC, those who are responsible for grant funding, as well as policymaking within hospital systems. That it does, I just, it feels a little bit, it feels very frustrating to know what the evidence is, to know what the benefit could be, to know how even, it's more cost effective as well. And we've done some research around that. And yet you cannot get it implemented within hospital systems.
Mel:
[19:59] Well, it doesn't fit the Western medical philosophy. So it's the same, you know, Heidi and I would know that it's an uphill battle to provide women with women-centred care by their own midwife as a private midwife working in a home setting because it doesn't match the medical philosophy that society would like to uphold for us as citizens. And so this really does sit outside the Western medical framework, which in itself could explain why there's an uphill battle for the use of acupuncture at this time in women's lives. Exactly. Yeah. Heidi, can you give us some insight into some things that you've used acupuncture for in your clinical practice as a private midwife?
Heidi:
[20:46] I can, Mel. I've used it for lots of issues that women have in pregnancy. So pregnancy provided for women with nausea and Vomiting for any emotional concerns, birth trauma, migraines, heartburn, constipation, hemorrhoids. Putting press needles or needling for hemorrhoids, it just draws everything up. And women who I've provided the needling to text me the next day and go, I can't feel the heaviness anymore. I can't feel them. Insomnia, itching. So the start of cholestasis, if you get it early, then it can help to reduce the heat in the body. Same with thrush, edema, anemia, because the needling can help the flow of blood around the body.
Heidi:
[21:38] Then threatened miscarriage, there's some research on threatened miscarriage. I love when we do needling or acupressure on IUGR and SGA babies, we can see that within a week the baby has doubled weight. Low AFI, blood sugar regulation with diabetes, pregnancy-induced hypertension before preeclampsia, we want to get it early. Big one is sciatica and lower back pain and symphysis pubis pain. My favorite is birth prep. So from 36, 37 weeks gestation and then labor activation around the 40 weeks, unless it's clinically warranted beforehand if a woman is looking at an induction. I just love that when you offer a pre-birth treatment, it helps to build stamina, relax the ligaments, it calms and grounds you,
Heidi:
[22:29] Tones the uterus so you have an efficient labor, ripens the cervix and assists baby into an optimal position. So anecdotally, we see women going to labour within 48 hours after a pre-birth treatment for multis and for primips after a labour activation within about 48 hours, if the mum and the baby are ready. But most of the time we see it happen within that timeframe. And then postnatally as well, we're seeing women who have mastitis, early mastitis, get onto it early there, great for low supply and milk letdown.
Heidi:
[23:06] There's also afterbirth pains and women who have had suturing or swollen vulvas and perineums, and it's great to reduce that heaviness and increases the healing time. Plus diastasis separation and for caesarean birth. So post-caesarean birth recovery, we have protocols for needling and moxa, which is moxibustion, around the scar. And if any women still have numbness around the scar, even 5, 10 years later, Moxa can help with that numbness feeling as well. And then in labour, it's amazing because it helps to reduce labour time and delay to retain placenta. You know, sometimes the placenta just pops out, plops out really quickly after needling. That's what happened to you? That's what happened.
Mel:
[24:00] As you were talking, I was kicking off a mental list of all of the things that I used acupuncture for in my pregnancy and labour and afterwards. Because you know I always propose to my clients I think you should have a body worker some kind of maybe an osteopath or a chiropractor I think you should have an acupuncturist in the same way as women will have their own family GP often you know you're like this is my GP I think you should have an acupuncturist a naturopath a chiropractor or osteopath and then obviously your own.
Mel:
[24:37] Understanding of how to maintain good health, you know, being outside and exposure to light and movement and all these things. But I really feel that having an acupuncturist or a traditional Chinese medicine practitioner as part of your health practice, as you said before, it's such a preventative modality rather than this rescue medicine that Western ways of thinking about health often think about medicine as rescue medicine rather than preventative medicine that can actually stop issues from happening. I definitely used acupuncture to get pregnant with my second baby in the same way as you described. So, you know, I had identified that my cycle was starting to lengthen and I went to the acupuncturist and she said she gave me a little schedule that we were going to follow for that month. She said, let's initiate a bleed, which was late at that point, so she initiated my period.
Mel:
[25:35] Then I saw her through that for various appointments and then at various days in the cycle, you know, we had sex during the time where you'd hopefully make a baby. And then again, yeah, went for a few visits after that.
Mel:
[25:52] And I was pregnant that very first cycle. You know, it all just adjusted itself back to what I was used to for my cycle. And then, yes, the pregnancy nausea. I ended up seeing her probably every three or four days to keep that under control and I would notice an improvement and then a gradual return of the nausea again and I'd go before, you know, before I started constantly vomiting.
Mel:
[26:17] And then I saw her for fetal positioning during a few of my pregnancies. And for my first pregnancy, she came to my birth because I was fully dilated with no contractions for over eight hours. And I mean you'll hear my birth story at various locations on this podcast you know scattered about in another podcast but she made the real difference in my first birth for getting out the baby and then remembering as you said you know plopping the placenta out after 36 hours of labor getting those contractions back to have my placenta and just looking at my midwife and saying I don't want to do any more contractions and she looked at the acupuncturist and said have you got a spot you could use and she went yep and so she popped a needle in and out like plopped the placenta I didn't have to do one other single contraction so I I personally have experienced the impact of acupuncture and so the fact that you're saying that yeah there's actually this there are protocols and evidence around using this through pregnancy for women and afterwards, it mimics my experience for sure.
Heidi:
[27:30] And I think it mimics for a lot of women who use acupuncture. And unfortunately, it's just not available in the hospital system from an acupuncturist or from a midwife providing it. We're lucky being private midwives in that we can, I can offer that service to women in my care, but it's not widespread. But then acupressure, you know, teaching acupressure, that can also help. You know, Kate has a great cheat sheet on her website that really shows you what points you can press and what support people can press to help the baby, help the mum, help the labour.
Mel:
[28:13] Does acupressure have the same impact as acupuncture?
Kate:
[28:18] Very, very good question. Acupressure is a really interesting modality, and it actually wasn't so popular in China. This acupressure applied to labour and birth has been much more of a Western model. Idea. And it grew out of a desire for women to have some autonomy, to be able to provide pain relief, where we couldn't go into labours. We can't be in the hospital. We can't do acupuncture, but we could use acupressure. So acupressure has always been around, but it hasn't really been applied to labour and birth until relatively recently. And a lot of that was the work of and then in America, Claudia Sitkovitz, both of whom have fantastic books for anyone who's interested in applying that. In Australia, there's a few people who also do it, including me, who train midwives. The evidence around acupressure has been interesting. In the Cochrane Systematic Review, which was updated in 2020,
Kate:
[29:24] Caroline Smith led that and I'm on the part of the team of that Cochrane Systematic Review Team. We separated the first time there's been enough evidence to look at acupuncture separately, acupressure separately. And in this diverging evidence, we can see for both that there's good evidence for pain relief, good evidence for pain modification, so perception of pain, good evidence for less pharmaceutical pain medication used around those things. For acupressure in particular, we've seen a reduction in cesarean section because
Kate:
[29:59] of its capacity to be able to manage the labor throughout. For acupuncture in particular, they've seen differences in neurohormonal activation. So there's some slight differences, but the main big one is around being able to facilitate acupressure, being able to facilitate longer term within labor because generally the acupuncture is a single intervention and then it doesn't continue in the trials. So the trials don't always mimic real life as well, often don't mimic real life. But acupressure, you can use throughout the labor and various people can do it. Anyone with fingers and thumbs can do it. And so it's very, A, cost effective, B, transferable, C, effective, and women really like it. And I have a couple of clients where I always do birth prep with a partner and a doula, whoever, mom, husband, partner, whatever.
Kate:
[30:52] We do birth prep and sometimes then they come back. I always do a postnatal, complimentary postnatal, to make sure that we've been able to catch anything that might have happened in the birth, an opportunity for a debrief, to be able to manage anything that's kind of cropped up and check in on breastfeeding and things like that. But you also hear the story. And sometimes they've said, oh, this point on my hand...
Kate:
[31:15] It was amazing, and they've pointed to completely the wrong spot. And it's made me realize it doesn't always matter if you haven't perfectly got the right point if the woman feels supported. If she felt like she was getting what she needed, her partner was involved, probably a lot of the hormonal intermingling between the partners, that does a lot. And so acupressure brings other people into the birth space with that woman and allows her to feel supported and receive a treatment, receive nourishment, receive that person's energy or chi. It provides a lot of things where previously I think there was gaps. And if you give them some massage, acupressure, breathing techniques, things that in the kind our session that I do with partners, we work in how to do acupressure, massage, what kind of pressure, how to do breathing techniques, eye contact, and physical proximity. So you're implementing three or four different things all at the same time, ostensibly just delivering acupressure. And so it really does help to bring other people into that space. And I think the evidence does show that it's got a longer effect in labor where it actually does affect birth outcomes in a different way.
Mel:
[32:38] Yeah, so it's got the added benefit of somebody that you love and trust being close to you and supportive in the birth space and not distracted, which we know already, you know, I mean, there's stacks of evidence on just the fact that having somebody close to you, giving you attention and one-on-one support in itself is beneficial. And so then if you, extra bits of acupressure, then it can accentuate just those benefits that women would already feel from all the other bits.
Kate:
[33:11] Exactly. And then we also saw in another review that I did, there is some point specificity as well. So if you're looking at the effect of trials that mainly used this hand point that most people know, so the hand point large intestine four, when they use that, which is for beta endorphin release, and we've seen under imaging that that releases beta endorphin in an anticipatory release. The studies that predominantly use large intestine 4, we saw that less pain medication was used. When studies predominantly used BLEEN6, which is the inner ankle point, which is the oxytocin point, we saw that labours were shorter. So using one point to regulate and establish contractions makes the labours shorter.
Kate:
[33:54] Using another point for pain management requires less pharmacological pain relief. So using the two, and there are some other ones as well, but those two in particular, there's enough evidence now that we can see the impact in the point's specificity.
Mel:
[34:08] And so you've got a little sheet on your website, you said, which shows those little points that people can use. Is that right?
Kate:
[34:16] Absolutely. That's freely downloadable. You can go to the website and it's a little cheat sheet. And there's also, for a small cost, a video course. So people can buy the video course and it takes them through how to do it, how to apply it, what points are used for and what it looks like in real life.
Mel:
[34:35] Yeah, we'll be sure to link that in the show notes. So anybody keen to add this to their toolbox for labour?
Heidi:
[34:41] And even in labour, I have myself or had the partner provide acupressure at gallbladder 21, which is on top of the shoulders. It's amazing in the pushing phase. So I've seen it reduce this phase significantly. So you press it every contraction. And the woman who I provided to stated she could feel the baby move down quicker when I did press gallbladder 21 compared to if I didn't. And I actually had press needles in there at the same time, which was an extra stimulation, but press pellets or acupressure can work just as well. And then the same with spleen 6, which is the inner ankle point, can move a cervical lip in two minutes. Bladder 32 on the lower back can establish labor quicker. And bladder 67 at the little toe can move a posterior baby to anterior in about five minutes. Not all the time, of course, but most of the time I've seen it happen. Recently, I attended a hospital with a woman pre-labor at 41 weeks, and she had extreme flank pain. So we suspected an abruption, of course. However, on the scan, it was found the baby had turned breech. So immediately, I pressed my fingernails into blood of 67, and we all watched on the scan as the baby moved catholic within a minute. Even the reg asked if we were all seeing what she saw. So that was amazing.
Mel:
[36:05] That's powerful. And so with the posterior, because you're doing a study at the moment, Heidi, where you're training midwives with the points on how to rotate a posterior baby in labor. I have received your training on that and was part of the study. And so we got taught to put the little acu needle points in the toe. And then I'm assuming that the point that the other one that you gave us, the four fingers above the ankle, was that called, what was that one called?
Heidi:
[36:38] Spleen 6.
Mel:
[36:39] Spleen 6. So combining, you're saying combining spleen 6 with the little toe point could rotate a posterior baby in five minutes.
Heidi:
[36:49] And so we're finding that spleen 6 helps to dilate the cervix and then the blood of 67 helps the baby to move. So, the combination of those two. There are other points that you can use, but I just wanted to concentrate on those because there's no evidence on needling for posterior position or varied position. I don't like malposition or malpresentation.
Mel:
[37:15] There isn't any research because I looked, I tried to find it. I wondered if you had any thoughts about the mechanism for why these acupressure points work for rotating a baby and changing their position.
Kate:
[37:30] There's going to be better, bigger explanations, but basically What we see is when these points, so when MOXA is applied to the little toe as well for breeches, so thermal stimulation, and MOXA works on the far infrared spectrum, so there's thermal stimulation, but there's also pressure. When you apply pressure at a moderate level, you're seeing the activation of vagal afferent fibres, and that has an impact on the vagus nerve and the diaphragm. It also sees there's micro-contractions in the uterus.
Kate:
[38:06] So there's some stimulation of the uterine cells through the fascial system. And so you see this little stimulation of the cells plus that fascial system that runs back through up the legs and around the back of the uterus.
Kate:
[38:19] And so that stimulation through the fascia, but also the mechanism that it stimulates into the uterus through the smooth muscle, that stimulates the baby to turn around or to get into a right position. You would apply it also with some postural positions as well to help. But also as Heidi's seen, I mean, Heidi's the one on the ground doing this. This is like really firsthand information about someone who's sitting in, you would say, a less than optimal position, having a scan done and applying pressure on the little toes and seeing the baby turn in that minute. So it has an effect on hormones as well as the muscle, the smooth muscle and the tissue, as well as the diaphragm, and they help to stimulate the baby to turn into an optimal position.
Mel:
[39:12] So when you say we can see it, are you still talking like those MRI studies that were done on working out other ways that acupuncture works is that they can see all that activation on a screen in front of them?
Kate:
[39:25] Yes. In Korea and China, they've got some fantastic capacity to be able to do more research because it's better research there. But there's a woman in Sydney, her name is Imqa Smith, and she's done quite a bit of research using MRI. She's a medical doctor as well as an acupuncturist. Look up some of her work. It's really amazing. Looking at primarily depression and looking at using different points and what happens in the brain, in the MRI scanner. And so there's some really good scanning and imaging techniques that you can see that you can see the mechanism of action. And in China in particular, they do lots of mechanistic studies. And Hong Kong and Korea, Those countries do good mechanistic studies, animal studies and human studies. So we've been able to get some of that imaging technology and see things like when you've had an epidural, if you use spleen 6, the inner ankle, it still stimulates contractions. And you can see it on the monitor in the room if they're being monitored at the same time. So you can see outside evidence of that, but then as in a proxy, you're seeing it on a screen as opposed to then the other studies where you're actually seeing the imaging through microvascular imaging, ultrasound, MRI, different imaging techniques.
Mel:
[40:46] Yeah, because I can feel that there's people in the audience going, oh, no way, putting a needle in, how is it going to have that effect? But you can actually see the physical effects on a screen in Western ways of monitoring.
Kate:
[41:01] People say, oh, there's no evidence. It's like, Well, there's no evidence in the journals that you're reading. There's lots of evidence, but it's often not published in those journals. But have a look. Yeah, if you have a look, there is good evidence. And anyone who'd like to look at those MRI studies from Imqua Smith, she's a Sydney practitioner. Really excellent studies.
Mel:
[41:24] Well, we've got a resource folder for every single episode of the Great Birth Rebellion podcast. So anybody on the mailing list actually gets sent a link to the resource folder for each episode. So we'll make sure that we get as many of those resources that you mentioned into the folder so everyone can get access to those as well. And I wondered if every acupuncturist is clinically prepared or confident in helping pregnant and birthing women. Is this a unique skill set or could any acupuncturist do this?
Kate:
[42:00] Another excellent question. No, it's not. It's not something that everybody could do. So if you are pregnant and you're looking for, or you've got pregnant clients and you're looking for an acupuncturist,
Kate:
[42:12] make sure that they've had some training or expertise in acupuncture for obstetric reasons. So there's a couple of, for anyone who's interested in doing that as well, there's a couple of things that you can do. It's not big in Australia, but we have, I'm part of a group called the Maternity Acupuncture Mentoring and Peer Support Program. So it's MAMPS. It's run through Healthy Seminars, which is a Canadian -based company. We mostly have American students, but we also have some Australians who've been doing this. It's a year or a 10-month long course where we meet twice a month and we train people and give them all the information about how to apply acupuncture in a maternity obstetric setting.
Kate:
[43:01] Additionally, probably something that will be of more relevance to your listeners, I'm on the executive committee for a group called the Obstetrical Acupuncture Association, another Canadian-based organization. And it's where you can do competency training. So you've got competencies in maternity acupuncture. And we did a specific training on the protocols for maternity acupuncture, where we trained midwives and obstetricians in how to use acupressure in a maternity setting. But for acupuncturists, there's a couple of ways to train. You can't say you're a specialist in anything in Australia. You can't say you're a specialist in maternity because there is no real such thing. But you can say you've had specific training and you can get that training through. There's some training through Chinese medicine education through China Books. There's training through OBAA and through MAPS.
Kate:
[44:00] But Heidi and I started a part of the OBAA, which is the Obstetrical Acupuncture Association, section for midwives. So that midwives who've been trained in acuneedling or midwifery acupuncture, as it's called in other countries, can join this group to be able to get competency on the OBAA. So if you're interested in doing that and getting more involved in the midwifery acupuncture, acupressure training, there's certainly avenues to do that. Or if you're an acupuncturist, there are avenues to train in maternity specific areas.
Mel:
[44:33] So what I'm hearing is that there are courses that acupuncturists can do to upskill, that midwives can do to upskill. And then when women are searching for a clinician to help them through their pregnancy or to have, you know, their own personal acupuncturist than just to be confirming with them that they're confident and trained in pregnancy, birth and postpartum techniques.
Heidi:
[44:57] Exactly.
Mel:
[45:00] I wondered if you could run me through the process of turning a breech baby. So, you know, women, about 2% or 3% of babies are breech at full term. And unfortunately, here in Australia, what we have been learning is that the majority of those will be born by cesarean section, mostly because practitioners have lost the skill of vaginal breech birth. We are trying to bring it back, thankfully. But if a woman does want to turn her baby head down, what's the process of doing that using traditional Chinese medicine techniques or acupuncture and moxibustion techniques?
Heidi:
[45:39] Sure. So there is a protocol based on a Delphi study that says using moxibustion between 34 and 37 weeks is the best time. So it involves using moxibustion or called moxa with or without acupuncture to turn the baby. The moxa herb is burned directly above the bladder 67 point on the little toe each day for 10 days for 20 to 30 minutes with a further five days of treatment if it's required. So other points to needle can be added to the treatment for ligament release, increased amniotic fluid and blood flow to assist the movement of baby. And MOX can also be used in combination with an ECV. So we do have a needling protocol that is used immediately pre and post version. And evidence does suggest that if an ECV is attempted, combining MOX and or acupuncture with the ECV manoeuvres improves effectiveness greater than each of the individual therapies on their own.
Mel:
[46:44] So we can combine MOXA, acupuncture and ECV to mitigate the effects of any single one of those. And the real benefit of MOXA is that women can do that at home. They don't need to go back to the acupuncturist every single day. It's a really easy technique.
Heidi:
[47:02] It's a great tool for women and their partners. You know, it's a time for them to connect, to talk about, you know, the upcoming birth or that they've got a breached baby. And it's going to keep each other accountable as well. You know, it is hard going home and having to do something for 20 minutes a day, but it's worth a try. It's a good time to connect. And you're connecting with your baby as well.
Mel:
[47:33] Yeah. And Kate, do you have anything to add to that?
Kate:
[47:36] Just a little on the evidence, possibly. There's a little bit of diverging evidence about whether to combine acupuncture and moxa. So most of the evidence is just around moxa. And moxa is a herb. It's an artemisium vulgarum species. It has been compressed. So it's in its raw form. It's very smoky and it's really, you know, it smells fantastic, but it's a bit strong. So what they have now done is compressed it into a little like a cigar type of charcoal dipstick, compressed and charcoal to make it smokeless. And it works on the far infrared spectrum. And what they're developing in Germany now too is pens, Moxa pens that have no smoke. They're not Moxa at all. They just work on this far infrared spectrum. And so they have also been experimenting. The Germans are way out in front of us with this kind of stuff. They've been experimenting with using that for turning broke babies as well.
Kate:
[48:35] So we see that on average in the research, MOX is about 50% effective and on average the baby will turn day three, four. But the protocol says to keep going to day six to keep the baby there. As the baby grows as well, 34 weeks, the baby's quite mobile. You want to correct other things like any anemia or blood deficiency. So you really want to correct those things where you can. Anything that might be contributing, correct. And there's some times where babies just are breached, something where you won't fix it and then it's meant to be, you know, a naturally occurring thing. And then it doesn't also interfere with the timeframe for doing ECV. And then, so I encourage all of my clients, talk them through the ECV process, what will happen when they go if the baby hasn't turned,
Kate:
[49:22] Try to demystify ECV and that people think it's so painful and terrible, but really work with them, set up the MOXA protocol before and after the ECV as well. And we see ECV on its own is about 50% effective. Moxa on its own is 50% effective. Combined, it's 65% to 70% effective. They don't interfere with each other time-wise or anything, so it's worth doing both if the baby hasn't turned. I've had a woman recently who was unable to use the Moxa because it gave her, she got very lightheaded, she felt a headache coming on, she found it a bit overwhelming. And so we did a bit of an experiment. And instead of 20 minutes per day, we did it until she felt the very first twinges of the lightheadedness. And so she was able to do seven minutes per day and that was it. And then she stopped and she didn't continue on longer than that. The headache was okay. The lightheadedness was okay. Baby turned day five. So it can still be effective with modifications. So you work with what the woman and the partner can do time-wise, response-wise, all of those sorts of things. So it's modifiable. And it's got a good effectiveness. And now the emerging evidence is put acupuncture in at the same time. But some people do, some people don't.
Mel:
[50:39] Yeah. And then what you're saying too, with the work that Heidi's doing at the moment, we don't yet have that quality of evidence for posterior babies, but that's what you guys are working on.
Kate:
[50:50] Which is why Heidi's study is so groundbreaking and fantastic.
Heidi:
[50:53] And I do recognize that posterior position can be a physiological state of labor, but But it's when it gets to the point where it's not and women are in pain, they have the back pain and they're asking, what else can we do? So, you know, midwives use their clinical judgment on when it is a good time.
Mel:
[51:13] There's two sides of the coin with posterior. Some midwives fall completely on the side of, you know, it's just a physiological difference. But we do also know that there are sometimes pathological maternal or pathological fetal reasons for why they're not turning and getting into that position so while it would be lovely to be able to fully trust physiology every single time sometimes physiology can take a long time and it can be more painful and then sometimes can lead to pathology and so yeah I mean if we got a simple solution to reduce the length of labor and reduce the amount of pain that women are in I just can't see a reason why we wouldn't unless and this leads to my next question do we have any information about the possible side effects or ill effects to using acupuncture you know we've just focused on all the amazing benefits but if we use it poorly or inappropriately or even if we use it appropriately, is there a chance that it could be actually damaging to a woman and a baby?
Kate:
[52:22] I would just give you a little bit, and then Heidi's got some other good information about the common side effects. So there are some common side effects, but of the very uncommon side effects, the commonest would be a pneumothorax, and that is from poor needling technique. So knowing your anatomy, where the points are, so the points at the top of the shoulder, the points on the chest, the points on the upper back, those points need to be needled at an oblique angle and shallowly or using breast help.
Mel:
[52:56] You're saying that the practitioner could accidentally actually puncture the lung through how deep they put the needle in. Yes. So it's not like if an appropriately placed needle is not going to create a pneumothorax, you actually have to physically puncture the anatomy with the needle that's far too deep.
Kate:
[53:13] Yes. Some people, it may not be far too deep on a person who's very slight. So you need to just be really careful in those areas and know your anatomy and be trained properly. Physiology shifts in pregnancy, so you want to really be careful about understanding Western physiology of pregnancy to know what it is that you're trying to affect and what it is that you might do. So preterm contractions and preterm labor are the risk for pregnant women or exacerbating any pre-existing conditions. if you over-treat or if you treat incorrectly. So knowing if you've treated incorrectly, what to do. But pneumothorax is probably the thing on the Chinese Medicine Council, the commonest uncommon event. And of the common side effects, Heidi's got some sort of first-hand experience just in hospitals and things.
Heidi:
[54:08] And in terms of pneumothorax and needling around organs, we don't teach that. We use press needles, which are a tiny needle instead of the longer traditional needles. Um, there are side effects, but they're very minimal. So usually it's sensation. So when you do needle a woman, um, they may have an achy feeling or, um, sort of a dull, just a sensation. And then it should go within about 10 seconds. Sometimes it can be a bit nervy, which you know that it's probably touched a nerve. So you've got to move it out from the nerve or take it out altogether and reposition it. And then there's like bleeding. Sometimes when you take a needle out, there can be slight bleeding. So you just put some pressure on it and sometimes there's bruising. But it's so rare. You hardly see it.
Mel:
[55:04] So it's more just the little, the impact of the actual needle on the physical tissues in the area. It's not like you could put a needle in and give someone a heart attack or a migraine or it's, you know.
Kate:
[55:15] Well, you could if you overtreated someone. So understanding what overtreatment looks like as well. If someone's very sensitive, you want to start off assessing their sensitivity. Some people respond super, super fast, which is also why in the acu-needling course that we run, we really look at how do we get feedback from the body? Like what are the reflexes that we're looking for? What is the responses that we're looking for? It's not just a matter of sticking in needles and going, well, then that's the one that It says it's supposed to reduce itching, but we'll just have to wait an hour and see. You get feedback immediately. What are you looking for? What are the things that the body should be responding? How are the reflexes responding in the body?
Kate:
[56:00] And then if you're seeing someone who is potentially having an adverse reaction, what are the rescue points that we can use? The commonest sort of more serious thing that I reckon that I see is people have a major fatigue. So if you're feeling particularly fatigued where you want to go home and have a good long sleep after you've had acupuncture, that's over-treatment. So you don't want someone to walk out going, oh my God, I feel like I've been smashed by a truck and saying, oh, that's great. You're really relaxed. It's not relaxation, that's an overtreatment. So being aware of that, the sensitivities of people, any skin reactions, some people have a reaction to the needles. So you just, there will be uncommonly, but there's every now and then, or someone who feels faint or nauseated. But what you do, how you manage that risk or the adverse response, how you manage that is important and a big part of acupuncture training or acuneedling training.
Mel:
[56:57] And it sounds like it could not necessarily be a problem in the body. Could that just be people feeling the change that is happening in their body quite dramatically?
Kate:
[57:10] Yes, it could be, but knowing the difference in that. So some people are like, wow, I really felt a big shift. But if you're feeling like nerve pain and someone says, oh, look, that's just part of it. It's fine. Nerve pain is not normal. or someone who feels acutely nauseated is not normal or feels really dizzy and faint, not normal, things like that. But some people go, wow, I felt a total shift. But really listening and being with the woman, understand, like a midwife, you know, a good midwife will stay and assess and watch for something that's a normal discomfort versus a pathology. Yeah.
Mel:
[57:49] Heidi, did you have anything to add to that?
Heidi:
[57:52] I just wanted to talk about the contraindications with acupuncture because there's different international policies. So in New Zealand, there's a hospital policy that states that intoxicated women and women who have an infected area are not to be nadled. And in the German guideline, contraindications include placenta previa, preeclampsia, a pathological CTG, increased chance of bleeding and mental illness or difficulties. And fair enough, if a condition is critical, such as preeclampsia, then no, don't needle, but great for PIH to reduce preeclampsia forming. If a woman has a bleeding disorder, acupuncture is not usually recommended. However, I cared for a woman who had a mild von Willebrands and put pressed needles at spleen 6 in ankle point a couple of days before her labour started. And she ended up having no PPH compared to the PPH she had in her first home birth. So you've got to look at the clinical picture in collaboration, of course, with the woman to decide if needling or acupressure is really appropriate.
Kate:
[58:59] And also knowing when to refer. If someone comes in and they go, oh, my palms and feet are really itchy and you suspect there might be something going on, always say, look, maybe it's not. Maybe you've just got a little bit of an itch. But in case it's something more, a little bit more serious like cholestasis, you should get in touch with your midwife. Really, you've got to be alert to when the referral is important and appropriate and when you can use things like forbidden points. So you're not supposed to use points before 36, 37 weeks pregnant. They're called forbidden points because they induce labor. So you don't use, some of those points are also used for back pain. Don't use those points for back pain in early pregnancy, which is why you want to see someone who's a pregnancy specialist to understand the difference between those points used for back pain versus those points used for labor induction, why I wouldn't use both of them. And in those situations, we're a supportive, we're not the main medical, modality, we're supportive modality and it's allied health or complementary health. And you're supposed to keep an eye out for any kind of clinical situation where you need to refer or where you need to manage something differently. There are a few things that we go through in any of our training that people should know about as contraindications.
Mel:
[1:00:17] I guess what I'm hearing is is that acupuncture is incredibly powerful to create change but that it does require a wise, skilled clinician to apply it. It does.
Heidi:
[1:00:30] Which is why midwives are in the perfect position to provide needling and acupressure and, you know, teach and support partners to provide it to the women.
Kate:
[1:00:42] It is a combination of two skills that requires specialist and specific training.
Mel:
[1:00:48] For midwives who are listening, where would you recommend they go to get this type of training?
Heidi:
[1:00:55] There are lots of courses, specifically the Acunelian for Midwives course, which Kate and I run, but also there's a course in Melbourne, a master's.
Kate:
[1:01:09] Endeavour, RMIT, Western Sydney Uni, they're the main providers. Endeavour do the master's, sorry, Western Sydney do the master's. Endeavour does a three-year undergrad where you get recognition of prior learning?
Mel:
[1:01:25] These are courses that midwives could do. In addition to their midwifery training, they get some recognition for prior learning. So it'd be a university course or a college course.
Kate:
[1:01:38] At Endeavour, you get a bachelor's degree. It's a private college, but you get a bachelor's degree, you get some recognition of prior learning, and you can do a three-year. So it's in total a three-year degree. Which is fantastic, with recognition of prior learning, I think up to 25% or 40% or something. But the Masters at RMIT, there's a Masters in Herbal Medicine and a Masters in Acupuncture. So we do a basic course in the acuneedling. Then we have an advanced course and then we have a master program. Theory component's quite extensive. So it's not just this weekend. Online theory and then case studies afterward, application, sending in proficiency tests things like that so it's it's extensive but doable with lots of support so we've got a very vibrant online chat support group and there's also acupressure training so hospital-based acupressure training where we come to the hospital and train people or do private courses in acupressure training for those who want to apply it solely in the birth setting for midwives who just want to do that. Plus, we still have an acustimulation course. So we've got things like cupping, press tacks, press magnets, acupressure. So it's a little bit more than just the acupressure. It's about stimulation with other things.
Mel:
[1:03:04] Well, I will make sure that we include all of that information in the show notes as well for anybody interested.
Kate:
[1:03:09] And hopefully ongoing within that hospital system so I think there's a big part to be played for humanizing and woman-centered care it was amazing
Heidi:
[1:03:21] I'm very excited to look at where and how we can get these complementary supportive techniques into different birthing spaces and pregnancy spaces, not just home birth, not just pregnancy.
Heidi:
[1:03:39] It can be for all women in all settings.
Mel:
[1:03:42] Yeah. And I was going to ask, have you encountered challenges to midwives actually being able to use these skills in a hospital setting? You know, everything requires a policy these days and can midwives just do the training and then go ahead and offer their clients this kind of treatment in a hospital?
Heidi:
[1:04:00] Not at the moment. So the Gold Coast University Hospital are working towards that and it will be good to do some research around the implementation of that and the outcomes for women and the You know, and further down the line, hopefully it will get into more hospitals. Once one hospital takes it on, I'd like to hope that every other hospital is going to see the benefit in it.
Mel:
[1:04:29] I mean, I wonder if a workaround, if you happen to have a continuity of care midwife, if the continuity of care midwife teaches you some of the skills through pregnancy, potentially the women could apply it to themselves. There's no rules around what women can do for themselves. And I wonder if midwives could also apply their knowledge of acupressure in that space instead as an alternative.
Kate:
[1:04:52] That's the real value of acupressure, is being able to use it in the hospital system and be able to apply it in the antenatal space by telling women what they can do for themselves. So your acupressure is so valuable in that instance. So it's really popular. Women love it. There's a great effect. it's cost effective and yet like continuity of care it's not widespread it's not rolled out and it would be really great we tried to do a trial of it at hospital but it required funding and we were not successful with the funding well
Mel:
[1:05:22] We're stuck in a medical vortex that doesn't believe in anything that doesn't bolster up the authoritative knowledge you know we know that it's that, There's no interest in anything that competes with medical knowledge. Yeah.
Kate:
[1:05:37] If anyone's interested in, you know, if they've got some position within a hospital where they could see the implementation of a pilot to just evaluate how a service might be utilised, you know, we would be so just more than interested to do it. We just, you know, probably need about $20,000. We'd just do that trial. Some justice to be able to get evaluation.
Heidi:
[1:06:00] So watch out for some crowdfunding opportunities.
Mel:
[1:06:05] Do you know what I can also imagine, though, is if it has the impact that you say it does and that the research has shown that it does, then actually a hospital would save way more than $20,000 if they invested in even just one acupuncturist to be present to assist women. Then I would think that the savings would almost be made in a week.
Kate:
[1:06:31] Just if you saved a few caesareans from breach or hyperemesis or, you know, like presentation to emergency department for hyperemesis is something like $2,500 to $3,000 per day. If you saved a woman from a presentation, look at the cost saving there.
Mel:
[1:06:51] Yeah, but even I think, you know, shortening a labor, a posterior labor for a woman who may have needed an epidural or a manual rotation or forceps or vacuum to assist with that. Yeah, cesarean sections for breach. Even a normal vaginal birth without complications costs the government somewhere around $20,000. So the more complex a birth gets, the more expensive it gets for the hospital and.
Heidi:
[1:07:19] And we've seen a midwife actually put press needles into the bladder 67 point for a direct OP baby. The womb was fully dilated. The CTG was becoming pathological and the senior reg was doing a manual rotation because the other wasn't available. They could see that the baby wasn't moving, but as soon as they put the press needles in within two minutes, the doctor's, the baby's head moved and turned anterior with the manual rotation. And the doctor even said, it felt like there was butter under my hands and the baby just glided around.
Mel:
[1:08:04] So the application of the needles in conjunction with the manual rotations, the clinician could actually feel a change and then witness the impact that it had under their hands.
Heidi:
[1:08:16] That's right.
Mel:
[1:08:17] Maybe. Yeah. I mean, it makes total sense, but unfortunately, things that make total sense still aren't supported by a system that doesn't understand complementary therapies. So I would hope that this episode is going to go a long way in aiding people's understanding and potentially getting you some funding. If anyone has $20,000 or interested in crowdfunding for this kind of research, I would love to see it.
Heidi:
[1:08:45] And yes, that's the plan is to do some crowdfunding for research.
Mel:
[1:08:51] So good. I'm so hopeful for the work that you're doing, guys. And I do believe, I mean, you've demonstrated clearly that this stuff works. We can see what the barriers are to getting it implemented. And Heidi, I look forward to hearing the findings of your posterior position research project.
Heidi:
[1:09:10] Me too. I can't wait.
Mel:
[1:09:12] Amazing.
Heidi:
[1:09:12] And even if, you know, the medical system doesn't support it, it's not about them, it's about the women and having an option.
Kate:
[1:09:22] All childbirth education could incorporate these things.
Mel:
[1:09:26] This has been Acupressure and Acupuncture with Kate Levitt and Heidi Williams. All the resources will be, some of them in the show notes, but then if you're on the mailing list, check out the resource folder for all of the resources. To get access to the resources for each podcast episode, join the mailing list at melaniethemidwife.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.
©2026 Melanie The Midwife
