SO: Midwives, Birth trauma and Conclusion for the parents...

[BirthFree]

This is a spin off from the other thread...
But what should/can be done to resolve feelings, issues, etc.?

My MW that contributed to some trauma in my births does not want to talk about it. She may say she does, but she doesn't really want to discuss it. I'm interested to hear how others keep that door open so that if it needs to be done (discussion), the client feels like it can be pursued.

[MsBlack]

Before I answer...and I've been thinking about this since first reading this earlier today...I wonder--how do you know your mw doesn't 'really' want to talk about it? Can you explain what it is that makes you see her this way? I am not doubting you exactly--I'm just curious what signals you are picking up that seem to be stronger than her words expressing that she IS willing to talk.

thanks!

[Romana]

The doctor I saw for dd's birth (family practitioner; used to do homebirths; NCB-supportive) did ask me afterwards, at the first well-baby visit, how I felt about what had happened - but then didn't really give me a chance to speak, interrupting me to say I'd done a good job and moving on to the well-baby visit.

When I got pregnant again and saw him for my first prenatal, he asked if there was anything about the last birth that I wanted to do differently this time. Pretty much everything I suggested he was completely unwilling to do (i.e., no mother/baby separation right after birth; delayed eye goop; and pushing in a position other than on my back - he was only willing to do side-lying; squatting or all fours was totally out of the question).

Those kinds of responses made it clear that he was not interested in actually knowing what I'd like to do differently, and futher encouraged me to seek different care (I switched to a midwife practice).

I think there is a subtle but very important difference between explaining certain birth practices or choices and being defensive about them. It's a delicate line and I think it requires the HCP let down his or her guard somewhat. It's not an easy thing to do, and definitely a difficult conversation to navigate. But I think when done right, the reasons for certain actions can be explained to the mother without making her feel like they're excuses or she wouldn't be listened to regardless. Perhaps making a concession about something valid, but not necessarily important in the midwife's eyes. I'm thinking, maybe, how a proposal to transfer to the hospital is done. The mother may have perceived that she was being persuaded into it when the midwife really felt she was simply providing facts and options. But saying to the mother, "I see how the way I phrased that suggestion may have made it seem overwhelming to you" or whatever the mother is trying to express may give her the validation her feelings need and keep her open to the midwife's comments regarding the ultimate necessity of the transfer, or what have you.

Just thinking out loud, because a small amount of humility/validation can go a long way. I hope that makes sense - and I do understand that those conversations need to be tempered with the midwife's need to protect her practice, her reputation, and be honest about having done what she felt was best for her client. I just think that a small chink in the professional armor can go a very long way to helping a woman work through and understand a traumatic birth.

[MsBlack]

Romana--

I'd say that what you've described are pretty strong messages about not really being interested in hearing you, in spite of verbalizing the wish to do so! Sounds like what that HCP was really saying was 'please tell me you had a wonderful birth and you're grateful for all I did for you'...and when you couldn't comply, the subject had to be rapidly changed.

I keep on thinking about this question posed by BirthFree. I have written some things which I keep deleting, this is hard to speak about! And for some reason I just can't call up my usual rambling and hope that it gets the point across somehow.

For now, I guess I just want to say that for some of us mws--if not all--really do think about this stuff. Really do want for our relationships with women/families to be real and responsible and responsive.

Maybe tomorrow I can be eloquent...

[doctorjen]

I think these kinds of conversations are really hard. As a birth attendant, I've attended births that I know were really hard or even traumatic for the mom. I luckily usually get a lot of contact with my clients after their births, sometimes for years (I'm a family doc and see their kids, their spouses, themselves for other issues) so I feel like I get a little better chance at hearing women's issues with their births, especially since these things often change over time. In the first week, and at 6 weeks, I hear a lot of women verbalizing things like "It was hard, but so worth it!" But sometimes when they come back 2 years later for baby #2 or subsequent, they are talking more specifically about things that didn't go well, or were traumatic, or have left permanent bad memories.
Mostly, I find it easy to discuss these issues, because I try not to be the decision maker along the way to begin with. It's rare for me to "do" something "to" a client, more often we talk things over and make a decision together, and later clients may say "I wish we would have tried x" but I haven't had a lot of folks say they were disappointed specifically in me.
There are exceptions to that, and I've tried always to listen and apologize, and only rarely if it seems like it will help, I try explain why I did what I did. Too often, I think we as care providers jump immediately to explaining and defending our actions, which then puts the client who already had to be so courageous as to speak their minds, on the defensive again.
I have had one situation I could not resolve, and I still feel it is unresolved and will probably never be resolved between the client and I. Basically, I made an error that caused her birth to be unnecessary traumatic. (I missed a transverse lie, did an AROM at near complete dilation thinking it would help the baby come down against the cervix better, and moments later we were heading for the OR for a cesarean for transverse lie with arm presenting) Despite multiple attempts on my part to accept that blame, explain what happened, and let the mama process what happened, she seemed to remain convinced that I intended to hurt her and hadn't taken her concerns seriously. No amount of me saying I was sorry and that I knew I was wrong seemed to help.
I know there is a perception among birthing women (myself included, believe me) that providers forget their births and aren't as affected by traumatic events, but in my case at least, I don't feel it's true. I am still fretting about things I did as a provider years later, and worrying that my actions may have caused harm. Maybe some of the midwives will comment and then I'll know if I'm just goofy or something, but I feel as affected by some of the births I've attended as my own childrens' births sometimes! I thought about hte above client's birth on a daily basis for a year probably, and often take a long time to hash out difficult births in my own mind.
So what is the final resolution? I'm not sure! I think sometimes things can't be resolved within any kind of relationship, and sometimes either person has to decide that their own healing is not going to include the other person if resolution just isn't possible. In the case of true negligence or dangerous behaviour on the part of a birth attendant, making a formal complaint is an option. In the case of less defined traumas, if the birth attendant isn't willing to "hear" you, perhaps closure can be had by a written letter detailing the concerns. At least then the feelings are given a voice, even if the receiving ear isn't ready for them.

[wumanh]

I think most midwives want their clients to be happy with their births and feel badly when they don't. The midwives I know always think about their transports or difficult births a lot. It is hard to hear that you may have contributed to a woman's trauma. Both parties need to be willing to hear each other.
Just as a midwife needs to think about how she phrases things, so does the mother when approaching the mw. Compassion, tact, allowing there might be something one missed or misunderstood can go a long way to having satisfactory communication.
Sometimes there is no "resolution" but maybe it's enough just to really listen to each other and acknowledge the feelings and that folks did their best at the time.
I am trying to develop my "tool bag" for dealing with birth trauma. Listening and flower essences and other energy work, gentle bodywork seem to work well.

[mothercat]

Hope and Healing conference

Midwifery Today is having a conference in Ann Arbor MI in May 2008. I have written to the conference planner asking about the offerings. They sent me an almost complete schedule. Among the speakers will be Penny Simkin who will be doing several sessions on healing after a traumatic birth. There will also be sessions detailing the different healing modalities that are used for women with PTSD.

Jan Tritten from MWT wrote that she thinks Penny would also be willing to address concerns from birth workers about how to heal themselves after a traumatic birth.

This conference will be a short drive for me and I'm glad to see that as HCP's this discussion is beginning.

And no, doctorjen, you are not the only one. Even for the births that go easily I spend at least some time thinking about how I could have done things better. The births that didn't go as well, I spend a lot of time thinking about what should have been different. It is what pushes me to keep looking for answers and improving how I do things.

[MsBlack]

For me, 'resolution' is:

highly individual....*I* might feel resolved, 'complete', the other guy might not (or vice versa). While it is important to be open to working through such things together, to acknowledge one's place in events and others' feelings, we have be mindful that one single 'event' is really various separate 'experiences' by the different participants. And at some point, we all have to understand that our feelings are *our own feelings*...and they stem from not just events and people in the present, but from our beliefs, our history, all that stuff I mentioned earlier. In any life situation (not just birth) where either me or the other guy just couldn't seem to come to resolution, I generally had to conclude that the feelings were rooted in things well outside of anything that happened between us.


something that may well come in stages over time--like grieving or forgiveness in general. One might feel 'pretty well over it', and then go through another cycle of feeling and realization later. Again, we can't take too much responsibility for how each individual woman processes things. I try to trust that each mom is fully able on her own life journey to work stuff out for herself, become more wise and strong all along the way. Sometimes that will be 'with me'--shared in some ways. Sometimes not!

[Romana]

Originally Posted by doctorjen

There are exceptions to that, and I've tried always to listen and apologize, and only rarely if it seems like it will help, I try explain why I did what I did. Too often, I think we as care providers jump immediately to explaining and defending our actions, which then puts the client who already had to be so courageous as to speak their minds, on the defensive again.

This is exactly what I was trying to say, not as well and from the perspective of the client/patient. I don't think you can reach resolution with everyone, though. I think there will, for some people, always be lingering questions, doubts, and perhaps blame. That is an individual thing and as a HCP you can't make yourself responsible for all of that. However, giving the mother an opportunity to speak, voice her concerns or issues with the birth, and giving some validation to her feelings can be incredibly helpful in her healing process.

I also really agree that the perception of the birth changes over the months/years. It's a huge event for most women, and processing the whole experience often just leads to more questions. I think it would be really helpful and valuable if HCPs were open to speaking with women about their births on multiple occasions as time passes. Not expecting HCPs to be counselors or psychologists, but just available to answer questions as they arise and listen to concerns or issues that the mother had. I know there are a few things I hadn't thought about until I was pregnant again and thinking specifically about how I wanted the second birth to be different from the first.

Ms. Black, I also feel that resolution is primarily an individual, and not a joint experience. I would however be deeply grateful for a HCP who was willing to try to answer a question I had from a birth that occurred two years prior (rather than just say, "Oh, I had to do that").

[BirthFree]

Originally Posted by MsBlack

Before I answer...and I've been thinking about this since first reading this earlier today...I wonder--how do you know your mw doesn't 'really' want to talk about it? Can you explain what it is that makes you see her this way? I am not doubting you exactly--I'm just curious what signals you are picking up that seem to be stronger than her words expressing that she IS willing to talk.

thanks!

Well, she will excuse anything away that makes her feel uncomfortable or make a statement that is really inappropriate (rude, or otherwise insensitive). She has said "Well it seems like YOU need to talk about it" vs. something along the lines of 'if you need to talk about it with me' or whatever. She is very defensive and I know quite strongly that it would fall on deaf ears or insanely offend her. To my knowledge she is not very receptive to any correction or discussion from peers or clients. I doubt very much I would be the exception to that rule.

[MsBlack]

BirthFree--

Thanks for elaborating for me. I do know what you mean--have certainly had encounters with people in my life (in various realms, not just client-provider) who could 'make noises' about wanting to hear and process together, but who were in fact too well-defended to ever let such a thing really occur. Would not really listen, were too quick to make it 'my' problem, etc--just as you have said it. I guess I just needed to feel certain that it wasn't only your assumption about the HCP--because this happens, too, sometimes; sometimes people are just afraid to talk to another about an issue, and do find that if they try, they are able to get a real conversation going. On the other hand, as a mw I have encountered several new clients who have complaints about this other mw--one they'd all used before. And to a woman, when they expressed complaints about her and I asked if they'd ever tried to talk to her about it, I was told 'she doesn't listen'. I actually tried to talk to her myself, attempting to approach in a friendly, open-hearted way, and she entirely blew me off, too. So--I KNOW there are people--and HCPs-- like this--"teflon egos": everything slides off!

I also want to say that while to some degree the processing of birthcare is 'individual', I do feel that it is at least in some part something that belongs to all involved. That the other guy's feelings/perceptions are my concern--and I do want to hear and share and grow through discussions about things, to offer and receive healing and understanding where possible--even tho this process can have mighty uncomfortable moments. But for instance in the kind of situation DrJen mentions...well, at some point the HCP can do no more, must deal with her own emotional fallout and leave the client to deal with hers. I guess I'm just saying there's a limit on 'mutual responsibility'. Perhaps we all agree on this already.

[MsBlack]

Romana--

Yes, of course you want to hear something, some explanation about why something was done. Unfortunately, the problem seems to be that way too many HCPs (incl. mws) have 2 issues with this:
1. THe current 'standard' for client-provider relations is heirarchical. The HCP is situated 'above' the client, is 'in charge' of things. A basic rule of maintaining authority is to be beyond questioning....start explaining, and then you have suddenly made yourself your client's equal forgoshsakes!

2. Many HCPs in my experience just DON'T KNOW 'why' they do something. NOt really....they haven't analyzed it too much. It is 'the way I was taught'; it is 'the way it's done here'; it is 'something I feel comfortable doing, and I'm not really comfortable with doing nothing' (which ties back into the heirarchy thing...because another way of maintaining authority is to 'do' things to another, things they don't know how, or cannot do for themselves). Often they just don't have a real good reason! And they go along and do things the way they do, comfortable in their place in the client-provider heirarchy where they are 'boss'...and feel happy to be 'helping women/babies'...and when questioned, are faced with the deep discomfort of having to actually THINK about it! Realize that especially in a hospital setting, drs and staff have were first given an education, and then had it followed up with daily work experiences, in which they had to swallow their own questions, deal with their own revulsion for the way things are done when they instinctively felt it was wrong...and so forth. These people have been deeply conditioned through their training and daily work to 'go along to get along' and to accept the rewards offered (money and power) that are supposed to help keep one 'happy': that is, with any private questions and misgivings quiet and suppressed.

So...you ask a question...and then maybe they are simply confronted with their own love of authority and will not 'stoop to your level' to answer. After all, acknowledging a question entails giving the asker as much respect as you want for yourself. Or maybe they are also confronted with doubt...because they don't know an intelligent reply. Or maybe also confronted with the world of hurt and anger they are keeping contained, made up of all the questions and bad feelings they had throughout their training and daily work, that they have been forced to suppress.

I have seen in my life that many if not most people really despise being questioned--and this goes triple for 'authorities'. I can't tell you the number of times that I have been severely 'slapped' for asking questions...even questions I asked in all innocent curiosity, only wanting to understand! A question is a threat, and again this goes triple or more for 'authorities'. That threat is a threat to their authority itself, a threat to their presumed power base. ANd on a much more personal basis, a question can be a serious threat to an individual's house of cards that is their fragile ego.

Mind you, if it's not obvious, I'm not approving of any of this I'm just saying that this is the way it seems to be.

[wumanh]

Just to throw out another thing- I have had clients miffed at me for NOT doing things! Like one woman thought I had not checked out her baby because I simply observed it while in arms, nursing, having her diaper changed all the while noting her color and tone, alertness, etc. I didn't do the medical thing of totally undressing her, etc. Some women want every thing explained in detail and others don't. Some want hands off and others want FHT taken every 15 min.
Everyone is different with expectations and what they see is good care and it is sometimes hard as a provider to find the balance for each woman. We can't read minds and it is helpful for clients to tell us what they need (if they know!) One client said I didn't give her enough technical explanations and I said if I had known you wanted that I would have.
It's a two-way relationship

[bionicsquirrel]

This thread has brought up a lot of difficult emotions for me. My ds is almost 5 and I still deal with stress and trauma on an often daily basis that is the result of the very difficult induction I went through. Without going into details, I still feel like my midwife is greatly to blame for my experience, as well as the medical establishment as a whole, the state I was living in for the strict midwifery laws there and the consulting physician who felt it was okay to make a decision about the health of my baby without ever meeting me or evaluating my records.
I have worked hard to let it all go, the fact that my midwife doesn't even recognize that there was an issue makes it difficult. At the same time, I don't feel like I have the strength to face her directly and ask her why or give her feedback. Then there is the other side of things, feeling guilty about "complaining" when I have a perfectly healthy son.
I think if a care provider cannot look objectively at her performance during a woman's pregnancy and birth and receive critism constructively, then they should get out of the business because there is so much more at stake here than a person's ego.

[MsBlack]

wumanh--

I can relate to this. Much as I try to help people understand, well ahead of birth, that I am *not* a doctor and will seldom look as if I'm acting like a doctor, some still seem to miss certain doctorly activities. Something seems missing to them if I do not perform the ritual according to med. customs. I have taken to giving a little lecture of sorts, in the final weeks of pregnancy--wherein I explain that as soon as baby is out, I will be very alert and absorbing a lot of information from the baby, but at the same time I'll be fairly hands off. They will be the ones whose voices are heard; they will decide when to pick up baby and how, and whether they need a blanket, hat, etc. I explain that a whole lot can be read about baby's health, just from baby's color, moves, voice, breathing. And so forth. Many families get it...some just don't--they want the usual ritual fulfilled and doubt that I could know enough about the baby without that ritual.

And you are so right--it IS a two way street, this relationship. For our own sanity we have to remember this.

[wumanh]

You are right that practitioners should be willing to take feedback.
I am sorry for your trauma. Would you mind sharing some of the things that have helped you? That way we can all learn.

[mothercat]

bionic squirrel

Having a healthy baby is NOT the only thing that matters. Women, especially C/sec. moms frequently hear this as though you should have to sacrifice all or part of yourself as the mom to be sure the baby is healthy. But the truth is that a healthy mom matters too. She needs to be healthy physically, emotionally, etc.

Gretchen Humphries who is a moderator on the Intl. Cesarean Awareness Network list has a website/blog <birthmatters> and has a very nicely done essay about this issue. Women who don't have a cesarean don't have the outward mark that also symbolizes the inward pain of a traumatic birth. However, that doesn't make it any less hurtful that you are being minimized and sacrificed for a healthy baby.

As for what to do about your feelings regarding your midwife, have you tried writing a letter. You don't need to mail it, but sometimes putting everything on paper can be very helpful. You could also mail it w/o expecting an answer or face to face meeting with her. There is also a symbolic "letting go" in burning the letter when you are done that can be helpful.

Have you tried looking through the thread that is linked in my siggy? There are resources listed that may be helpful.

[mothercat]

Talking with your midwife

I know that this is frequently suggested when there has been a conflict/misunderstanding, etc. but I just want to add a word of caution. It is not always the best idea.

If your midwife was someone who seemed to really listen and care even when things weren't going well, then she is probably someone you can go back to and discuss things with.

However, if you have even a vague feeling that she is blaming you in some way for what happened, or that she doesn't accept any responsibility for what occurred, then it's probably a terrible idea to talk with her again. If she couldn't be what you needed her to be at the time and/or she has been defensive and doesn't see that there is a problem, then she most likely also is not going to be open to even constructive criticisms or questions. What most likely will happen is that she will be defensive, or put up a wall and you won't get the answers you are after. You probably will end up more angry and hurt because although you are trying very hard to resolve things, the HCP is not invested in that resolution. Not to be hurtful, but in their mind you may have been written off as ungrateful and/or difficult. You aren't, but that is how they are protecting themselves emotionally from dealing with the pain they were a part of.

So ask yourself these things:
what do I want to gain from the conversation?
do I feel or think that she will be emotionally able to help me meet those goals?
how will I feel if those goals aren't met?

Then decide whether talking with her is a good idea or if you need to find another way to resolve those feelings.

[pigpokey]

One small thing to add: I think some midwives use the excuse "You can't please everyone, some moms get mad at me because I didn't do enough of a newborn exam, I didn't do enough vaginal checks" etc. in the face of a trauma report. But it is rare that a woman will get PTSD from such issues, though you may hear about them from clients and I would think you would use such feedback in refining your communications protocols. I'm not quite sure why those kind of issues are being brought up in this thread. PTSD / trauma comes from rape, fear of harm, fear of death to oneself or a loved one, that kind of thing. Not from "midwife asked DH to cut the cord not me," however, if you've created a scenario of disrespect in which the mother felt frightened of you, you may hear this kind of stuff in addition. I wish I could spend more time on this posting.

[bionicsquirrel]

I think the biggest thing that has helped me was getting involved. I was very depressed postpartum, but it didn't really kick in until 4 months. By then, I didn't think it could be birth related. Now I know I was and am still suffereing from PTSD. It took me almost two years of constant denial that the birth was the cause of my emotional distress to finally realize that the only way I was going to make things better was to help other women. I was ill for a long time with meningitis and during that period I hit rock bottom and faced a lot of my fears and issues. I woke one morning and knew that I was supposed to be a doula and now I am becoming a midwife. I say it a lot, I need to be the midwife I didn't have.

I have agonized long and hard about writing a letter to my midwife. I still don't have my records which I blamed dh over for too long. I need to just put on my brave face and ask for them. Postpartum though, I just couldn't even call her, I didn't want to think about her, the anger and resentment was immense, so I asked him to get my records and he just didn't understand. Now I have let go of a lot, I was able to grieve finally. I thought I was doing great for a long time, but about a year ago a friend was vbac-ing with my midwife as her doula and my name was brought up. My friend thinking she was helping told said midwife that I was still upset about the birth. Suddenly I had an email from the midwife saying she just didn't get it and wanted to talk to me because she thought my birth was great. I panicked and honestly, couldn't even call my friend for a long time. It all came back and it took quite awhile to bring myself out ofthe funk again.
Part of the issue is that I saw the midwife at 1 week and 5 weeks and everything was fine. I was that typical blissful mama, totally sleep deprived and happy to be a mom, to hold ds and nurse and snuggle etc. I hadn't processed the birth yet and midwife assumed I was content. It didn't really kick in until that 4th month, so she was already out of my life.

Sorry for the rant.

Part of this thread really makes me question how I help my clients deal with their own births, good and not so good. I want to be better at that aspect of birthwork because it is so important.

Last thing, I promise.
I saw the movie, What Babies Want, at a conference when I first decided to be a doula. That movie changed me profoundly. Something shifted in me and allowed me to be more objective. It really helped me heal a lot of grief with ds also.