Common Knowledge Trust was invited to participate in the 20 year Maternity Service plan.
These are the questions asked and our response.
Maternity Services QuestionsThese are the questions asked and our response.
From Wintergreen
Founder of Common Knowledge Trust
Producing The Pink Kit Method For Birthing Better®
P.O. Box 892
Nelson
What works well with the current services as provided by LMCs and the maternity service providers at the hospital – obstetricians, core midwives, anaesthetists, paediatricians ?
My experience with the Maternity Service since immigrating to New Zealand in 1995 has been very positive. There isn’t a problem with the maternity service. There’s a problem with the customers using the service.
I formed CKT in 1996 and have made innummerable efforts to get the message of the Trust heard … grow a skilled birthing population. Knowing how to birth/coach:
• is an essential and natural extension of pregnancy.
• improves the delivery of service because families cope and manage their labour experience better.
• Develops a truly balanced Partnership with Midwives.
• Improves the birth experience for families who need specialist care during pregnancy and birth … including elective surgical delivery.
• Improves the birth experiences for families who unexpectedly need more medical care while in labour.
New Zealand Maternity services are unique. No where else in the World do ‘choices’ for expectant parents exist at the level experienced in New Zealand.
Choice alone, even coupled with ‘information’ is not sufficient to improve birth experiences and apparently not sufficient to improve outcome or reduce the amount of medical interventions. In fact, ‘choice’ will lead to increased medical intervention as more women ‘choose’ … elective cesareans and epidurals.
If the goal of NZ Maternity Service is to reduce the c/s rate or intervention rate … including the use of epidurals then there are basically two choices. First, remove the options … such as establishing primary birth units. No choice … no epidurals, no c/s. This produces sever unintended negative side-effects. This excludes families who want or need increased medical care or access to pain relief from having a self-empowered birth. This implies that birth without epidurals are superior. Therefore women who choose or need an epidural are perceived of as ‘second class’ from those who oppose epidurals. At the same time those opposing epidurals are perceived of as ‘alternative’.
There is another option: grow a skilled birthing population so that all families use their birth/coaching skills in whatever birth unfolds. Why limit ‘good’ births by removing either ‘choices’ or necessities. Really this should be a no-brainer. Skills in any area are more likely to prevent, reduce or eliminate ineptitude. The statistics collected for 8 years that follow expectant parents who self learn Pink Kit skills then use them also show that they self-reduce their use and need for many of the common medical interventions. This is not the goal of The Pink Kit Package, it is an unintended positive side-effect.
Pregnancy is the appropriate time to learn effective birth/coaching skills and this should be encouarged by midwives, childbirth educators, GPs and Obstetricians as part of the responsibility expectant families take. This is an educational/social issue not a political one and would fit well into the Maternity Services offered in New Zealand.
Within the Maternity Services all birth professionals can ‘educate’ expectant families that learning how to birth and coach is important. There are a number of skills-based systems such as: Lamaze, Bradley and Hypnobirth. However, there are some deep differences between all the other systems and The Pink Kit Method For Birthing Better®.
• The Pink Kit Package is locally produced.
• All other systems carry an anti-medical ideology and attempt to achieve ‘natural birth’.
• Others systems teach ‘techniques’ that fail too often. The Pink Kit Method passes on skills based on human behaviors within the specific context of childbirth.
The PK is non-confrontational. The PK goal is to simply grow skills for this incredible event, experience, process and activity … the birth of our child. The skills engage and involve families in working with their baby’s effort to be born and are for all births including elective surgical deliveries.
I have a question to the DHB in response to the Summary sent me. Does the DHB see ‘delivery of services’ as the only dimension of Maternity Services? From the summary this appears to be the case.
If this is so, then don’t bother to read further. If delivery is the sole goal of your 20 year plan then you’re really only talking about professional stateholders. Although you ask for input this is not the same as involvement by consumers of your service. Although ‘choice’ has been the accepted form of involvement this has set up the birth issues that exist today.
That is why Common Knowledge Trust has made many attempts to have everyone consider another approach … grow a skilled birthing population.
What doesn’t work so well with the current maternity services ?
How can anyone say what doesn’t work well in the current service when there is no defined goal for what a positive birth experiences might look like. No one has ever identified what certain childbirth terms even mean: natural birth, normal birth, physiological birth, medical intervetion, medical birth. Why should any type of birth be better than another? Certainly any family considers the birth of their child to be important.
If the goal is to increase what midwives now name ‘physiological birth’ (isn’t all birth physiological?) by implication this means families who need or want medical care are religated to having a poor experience. That’s not right. Midwives have told me that they have to identify themselves as different from doctors … hun? They are different yet this difference does not have to be based on ideology as it has been. In simple form this ideology states that birth is unsafe (medical viewpoint) or safe (midwifery viewpoint).
However, the unintended negative side-effects of ideological birth are many. The two major ones are:
1. conflict between birth providers impacts the consumer causing consumers to align to ideology and an expectation for delivery of that ideology rather than understand their job in their own experience.
2. Consumers are caught in a polical dialogue rather than involved in the social factors surrounding their birth experience.
At the moment there can be no fault placed on either birth providers or consumers … in New Zealand there is no social expectation that expectant parents learn birth/coaching skills.
Certainly there is absolutely no indication that local midwives and doctors educate expectant parents to their need to come to their birth with birth and coaching skills … including c/s delivery although. In fact there is no indication that midwives and doctors even believe people need birth skills but from the different ideological perspective. Doctors basically don’t believe there is no way to prepare for an unknown event and midwives believe there’s no necessity because birth is natural.
Also the Maternity Service is solely focused on their delivery of service by self reflection on their care. This easily gets translated by families as an expectation that birth professionals provide them with the birth they ‘choose’, ‘want’ or ‘need’. Is that what the DHB or wants to promote? There are two important unintended negative side-effects to the present viewpoints surrounding birth.
• The greater the skill of any professional, the greater dependence by the consumer.
• A belief by professionals when working with a multitude of unskilled consumers that ‘it’s easier to do it myself (with my skills) rather than try to have them do it.’
From a medical viewpoint, consumers aren’t going to medical school in order to birth so ‘trust me’. From a midwifery point of view … ‘I can get the woman through birth’.
In NZ ‘childbirth choice’ was instilled in Maternity care. Childbirth ‘choice’ of course is not in itself a bad thing. However, it has some unintended negative consequences. Basically Birth Plans and ‘informed choice’ arose out of an anti-medical, pro-natural birth viewpoint.
• If ‘choices’ are available then they have to be accepted.
• When ‘choice’ is encouraged then trying to reduce the ‘choices’ families make can not be critcized.
Unless you fundamentally change the social fiber of birth, ‘choice’ must be always respected but then the MOH can’t be upset by the increase in epidurals and c/s rate. What doesn’t work well with the maternity service is a lack of moving beyond making ‘choices’ as the basis for ‘responsbility.’
When midwives achieved their professional success to become Lead Maternity carers they assumed more women would ‘choose’ more ‘natural birth’ and reject ‘medical birth’.
Yet, women ‘choosing’ a home birth will likely ‘choose’ an epidural as her pain relief of ‘choice’.
Also the use of pain relief in birth is promoted actively by all sectors by doctors: ‘You won’t have a root canal without pain relief’. On the other hand midwives promote a belief ‘you’ll instinctively know what to do on the day.’
Doctors and midwives see families making ‘choices’ that they can’t actualize on the day. Therefore the maternity service must re-evaluate how individual choice must be balanced by some other message.
This is an analogy. If society gave people the ‘choice’ whether to learn to drive a car then more accidents would occur with increased medical costs and auto repairs. Society has not taken that route. Instead every single person (regardless of background, education, ethnicity, socio-economics etc) who wants to drive is expected to learn the complex driving skills and must show their skills in a practical test.
Driving a car is an activity so is giving birth. How well a family has learned the complext skills will reflect on their ‘test’ … the BIG DAY.
This activity of childbirth is surrounded by many professionals which perpetuates the dependence mentioned above and belief by professionals that their skills will get the family through the experience safely. Up to now there is NO expectation that families need skills and need to use them.
Once again, growing a skilled birthing population is a social value’s issue that can be grown by birth providers.
I hear midwives say they want women to take more responsibility yet within their Partnership, ‘responsbility’ is defined by ‘making choices/Birth Plans.’
If society does not promote the concept that ‘taking responsibility’ includes self learning birth and coaching skills as a natural part of all pregnancies then consumers of your Maternity service won’t know. Once people know what is expected of them the majority will comply. Of course, there will be some who do not take this responsibility just as some people do not drive safely. But like driving a car, fewer than feared.
• Making ‘choices’ as the only expectation for ‘taking responsibility’ puts unnecessary pressure on all birth providers to provide outcome based on ‘choices.
• This does not create a well functioning Partnership with midwives.
• Nor do obstetricians get the pleasure of working with skilled families when more medical assistance is required.
The obstetricians in Nelson have refused to meet with me and conveyed through their receptionist because they are secondary care they have nothing to do with whether families come to birth with skills.
Any birth that requires more medical attention can still be enriched for the family by the use of their skills. This should be encouraged by obstetricians. Obstetricians should not feel such separation. I realize this has been caused by the ‘us versus them’ politics in birth, however, this has absolutely nothing to do with The PK. The Pink Kit fits well with the increased assessment, monitoring and procedures.
If midwives, GPs and obstetricians do not grow a skilled birthing population then they continue to support a consumer belief that ‘I trust that my midwife/doctor knows what they are doing and they’ll take care of me.’ This is ultimately the foundation of a ‘delivery of service’ and ultimately creates a passive consumer loaded with unnaturally high expectations.
In the past 35 years The Pink Kit skills have been used in absolutely all births because they are connected to pregnancy not birth choices or desired outcomes. During these years obstetricians who have encouraged the families to continue to use these skills have engendered extremely positive memories for themselves and the families.
The statistics collected by Suzie and Andrea clearly indicate that families who teach themselves The Pink Kit skills feel better about their birth experience even when a great deal of medical care is required. Obstetricians want to see positive birth experiences in every birth as do midwives. They should join in a social change toward growing a skilled birthing population. Supply The Pink Kit Package to their clients, encourage them (people respect what their birth professional tells them) to learn the skills and simply encourage them to use the skills throughout the birth process. This takes no time at all and will go a long way to stop the doctor versus midwife, natural versus medical or home versus hospital issues surrounding birth at the present and what causes the shame, blame and guilt experienced by many families.
There is one other thing that doesn’t work well in NZ’s Maternity Service. Unfortunately the Maternity Service promotes itself as providing services to ‘women, their babies and families’. Fathers are hidden in the latter. This is inappropriate. The woman does not come first, the baby second and the rest third. This has to be rephrased as ‘to families’. Women wanted their husbands/partner friends or relative to help them
I realize this concept arose through the Midwifery Model of care and has unintended negative consequences that impact the whole family.
• Fathers, are made to feel invisible. It becomes much harder to get them to be pro-active with due to lack of specific skills, a defined role as simply a ‘support’ and are really not part of maternity services.
The Pink Kit has skills that are equally learned by mothers and fathers (and/or any other family or friend who will be at the birth). The unintended positive side effect noted by equally skilled women and men noted by Andrea and Suzie is that couples who work well together in birth do better in problem solving during the newborn phase and experience less stress as couples.
Childbirth is no longer a ‘women’s only’ club. Skilled fathers excel in their job to help the woman cope and mange the activity of birth no matter what circumstances. This should actively and socially be encouraged.
Where do you believe any gaps in the services exist ?
The major gap is in what expectant parents should be expected to do for themselves. As mentioned above there presently is no social expectation that when you are pregnant you have to learn to birth and the person who will be there with you needs to learn appropriate coach/support skills.
Why self learning rather than the skills being ‘delivered’ in way of teaching or being done on ?
When you learn to drive a car, you primarily self learn. This is true of many activities from learning to paint or run a marathon. Self learning takes the form of practice, practice and more practice. Self learning can come from a ‘teacher, book, DVD or friend’. The Pink Kit Package is the best teacher.
• Childbirth educators already ‘teach’ a great deal of essential information. Midwives teach a great deal of information but do not see families frequently enough during the best learning period of pregnancy … 24 weeks through 36 weeks.
• Obstetricians role is not to ‘teach’.
• The role of all three providers in growing a skilled birthing pop should be to provide The Pink Kit Package and explain the importance of self learning.
Pregnant families are adults, they just need to know they have to learn skills and be supplied with the resource … their own private teacher.
From 35 years of experience, trying to ‘teach’ families has never worked. This produces unintended negative side-effects. Since there is no social value, expectation or example of even needing birth skills much less learning them as being like driving a car, learning an instrument or training for an athletic event …
1. Consumers in childbirth believe that what is taught by a professional is ultimately professional skills and will be done on them. This is coupled with the concept of ‘continuity of care’ … ‘my midwife will teach me how to birth and be my primary birth coach.’
2. Consumers do not own the the skills so essential for the activity they will do. Self learning = self motivation=self use.
Birth will take place in hospital for the majority of families. And there are many medical issues that might present themselves jeopardizing the safety for mother and child. Keeping to our driving analogy. There are mullitudes of people with medical issues who drive yet all share the same driving skills in order to drive safely.
The Government educates people all the time as to the appropriate and inappropriate use of a vehicle. They decided to educate peopole because they were fed up with the carnage.
In childbirth birth professionals should be fed up with seeing women behave and act stressed in labour. They are already fed up with Birth Plans that fall apart because the woman doesn’t know how to cope with birth. This lack of coping by so many women indicates a lack of skills.
Birth professionals should also have little tolerance/ but sympathy for fathers who just stand around useless and helpless or are just hung on for hours. This indicates a lack of skills. But where do expectant families learn skills? They aren’t passed on through the generations. Primarily people don’t learn skills because they don’t know they have to. This is known as unconscious incompetency.
The contemporary ideology actually acts to de-skill people by emphasizing an instinctive approach to this physiological process. This would be no different than people being told they can intuitively tell a poisonous mushroom just because they are hungry. This produces conscious incompetency … a belief that instinct means one thing when it can mean something else. Left alone a woman can instinctively tense up to the painful sensations but eventually will give birth because 100% of pregnant women will give birth one way or another. This is no different than the concept of ‘natural’ birth … .without medical care available anything that happens in birth is natural and normal … including injury or even death. Birth is both inherently safe and unsafe.
Childbirth skills can be learned because birth is essentially the same … one contraction following another … in variation and uses shared human behaviors. These skills can then be used in any birth that has contractions and has been extended to those families needing or choosing a surgical birth as a way to increase involvement and enjoyment of this special time in life.
For home births, increased skills increase the safety.
The Maternity Services just does not have a vision for childbirth that is inclusive of all families and all births or moves beyond ‘service delivery’ and that is what needs to change and it can change within 5 years. The Midwifery Model of care has been in place for 18 years. It is simpler to get individual families to self learn skills for what they know is an important, life changing event then to grow a more skilled professional group … they are already highly skilled and delivering a wonderful service. Stop taking on more responsibility then you should! Share care.
Shouldn’t growing a skilled birthing population for all families and all births add some positive dimension? All birth professionals can supply The PKP to families and tell them that they need to self learn and why.
Although there are medical concerns surrounding birth, everyone knows that birth is unique and is an activity rather than a passive event such as a dental appointment. This acitivity will occur whether through a labour or surgery. This acitivity will occur no matter how a woman or man behaves, acts, copes or manages. Either way, women do not control birth however, any woman can control her responses to the experience and this is achieved through self learned skills. Any man can help her when he is skilled.
What do you want for your society? New Zealand could have the best birth statistics as well as the best birth experiences in the world when everyone involved changes the present social belief that ‘there is no way to know what your birth will be like therefore there is nothing you can do about it’. Birth is an activity that unfolds and pre-learned appropriate skills then become the default behavior. This means more birth providers see an increased number of women coping with birth better and a hugely increased number of men helping.
What barriers and/or difficulties exist in the provision of the current maternity services ?
My experience with Maternity services for 35 years shows that the barriers are several:
1. Putting the focus on opposition as mentioned above. This means families are asked to choose one or the other ideological viewpoint. This leads to blame, shame, guilt, confusion and side-taking. This is articulated in common comments by women: ‘I’m not brave enough to have a natural birth’ or ‘I have health issues which means I can’t have a natural birth’ or ‘I hate hospitals so I want to give birth at home.’ It’s not a good idea to have opposition as a basis for engaging in an activity.
2. An attitude that ‘choice’ and ‘information’ are the true basis for coping or managing the activity of childbirth coupled with a social message that ‘you’ll know what to do on the day.’
3. The belief by midwives that they are the protectors of ‘normal’ birth and doctors should be for providers only for birth problems. In fact, every family should have a midwife who gives them continuity of care whether their birth is ‘natural’ (never defined) or medical ‘(never defined) and the family should still work with their baby’s efforts to be born when they need or want more medical care. A family who plans a surgical birth should be encouraged to enjoy and take time to prepare for birth, learn the skills and use them during surgery and recovery.
Doctors should not be picking up the pieces or rescuing the failures and midwives should not be seen as shutting out families who need or want medical care. Birth is birth and all should be treated equally … a good dose of skills brought into every birth by the family will go a long way to heal birth within the social fabric of Life and lessen the political debate.
4. A belief by obstetricians that they are the ambulance at the foot of the cliff rather than a birth professional who works along side families who continue to take an active role in working with the birth process. A birth that requires more medical asesment, monitoring and procedures is still a birth that can use a good does of birth/coaching skills. Why not?
5. An unwillingness for midwives, doctors in Nelson and in NZ to take the Pink Kit skills seriously.
6. The lack of the DHB (until recently) and the MOH (who I’ve contacted several times) to consider what we offer is something of significance and should be treated as a ‘stakeholder’.
7. Placing too much emphasis on personal choice as the foundation for the jobs of the mother and father-to-be. This is the major educational hurdle that can only be addressed by constant education given by birth providers just as the Government educates the general poplation about drink and drive.
Andrea and Suzie have collected statistics for almost eight years. This is a long time to have this concept uninvestigated or even considered. And their statistics were achieved with an acknowledged imperfect resource. CKT would love the DHB in Nelson to partner with Common Knowledge Trust to produce a contemporary and thorough Pink Kit Package that families really would love to use. This would cost about $150,000 -$200,000 and produce at least 1000 new PKPackages.
Andrea has told me that the DHB has an interest in doing a 2 year trial when our new 4 Disc set becomes available. I have not heard from anyone to confirm this. This new resource is still imperfect. A complete overhaul is essential to bring the Pink Kit Package into contemporary form.
If you were to make improvements to current maternity services, what would they be ?
One thing that has to be sorted out is the cause of the increased rate of c/s and epidurals. In contemporary society we have to ask whether 1/3 of all babies or mothers would be dead or injured if surgery had not been performed? It is the maternity providers who know whether NZ is faced with an unrecognized health crisis. If there is one then speak up.
This is a possibiity just as there is a health crisis around obestity and higher rates of diaabetes. Perhaps modern women can no longer birth vaginally or without pain relief.
Then we must ask whether the use medical pain relief as a mechanism to ‘cope’ with the naturally occuring pain of labour is socially acceptable. Are there specific ‘health problems’ that increase the naturally occuring pain? Not to my knowledge. Therefore pain relief is a social option not a health necessity. Certain if a woman will have a surgical delivery she will require ‘pain relief’ .. that’s major abdominal surgery.
As mentioned above childbirth is not like a root canal or auto accident although health problems can be associated with birth. Once again the Maternity Service must identify what health problems actually increase the natural occuring pain so that pain relief can be used in those specific instances. Then consider the use of birth/coaching skills as the basis for birth management. This can only be achieved when the general population knows they must learn skills, with a resource available and with encouragement from birth providers no matter what birth unfolds.
No one wants a woman to suffer in childbirth due to the intense, even natural pain, however, The PK skills clearly show that women and men self reduce their use of medical pain relief because they:
• use skills to cope and manage the pain (not ‘reduce it’) based on preparation of the pregnant body. As one father said: ‘Before my wife had our first baby, I thought women had to have strong muscles to push a baby out so she did heaps of pelvic floor exercises. She ended up with a c/s. With the PK skills I realize women have to open up to let a baby out and my job is to help her do that while in pain and instinctively tensing up in response’.
Birth is still challenging and there are women who will still use medical pain relief along with these skills. As one woman said: ‘The PK was great, I had an epidural hours after I thought I would.’
The Pink Kit is 100% successful because success is broad. Either ‘teaching’ The PK skills or doing the ‘techniques’ on women does not produce consisent results nor grows a skilled birthing population.
Midwives who try to ‘do’ the PK have very irregular and unsatisfactory results. Although midwives have a strong ethos of ‘self reflection and improving delivery of their service’, there are some very important unintended negative side effects of delivering The Pink Kit through midwives.
• Doing so perpetuates dependency on the skills of the midwife rather than on their own set of skills and help from their partn.
• An underlying social belief by many women that if they can’t achieve a natural birth under midwifery care, they can’t birth or have failed.
Midwives must seriously consider the relationship they have with their clients. As each midwives is extremely skilled it is very easy to use their skills on families with no skills but this perpetuates the status-quo. We hear midwives says in response to the statistics ‘I have good statistics like that.’ However, the statistics were achieved by different means. The PK statistics are achieved by growing a skilled birthing population that is self taught and encouraged to use their skills in their birth experience.
Once again I believe the Maternity Services in Nelson and New Zealand is absolutely tops. I don’t believe the service per say has to change it’s delivery. They are all competent, skilled, caring individuals who are doing their best to provide safe and good births. For change to occur providers would do well to encourage another type of pro-active role for consumers. This should occur across all the birth providers and include all birth circumstances because good breathing, relaxation, communication and touch, staying open, finding positions that keep the labour progressive in no way conflicts with any medical care given.
At last there is a childbirth system for expectant parents that includes everyone and does not cause conflict anywhere. Isn’t that worthwhile supporting and incorporating into any improvement?
Given that this work is contributing to a strategic plan over a 20 year period what opportunities do you see for service development? What would your dream/vision be?
First, I think people have to realize a change in childbirth is imperative now. Think of all the positive changes that have occurred in the past 40 years … many. Now everyone needs to take a further step … a social step rather than political one. This type of change is more likely to occur in New Zealand that has such a wonderful maternity service with such flexibility than any other place in the world. New Zealand could lead the way.
There was high expectation in 1990 that the change to a Midwifery model based on ‘choice’ would head birth down one path. Everyone must be totally overwhelmed that birth has headed down the path it’s taken, but we could see that happen. When childbirth occurs in a high techical environment delivered by sophisticated skills of obstetricians it is very easy for the consumer to rely on the professional whether that is the goal of the obstetricians or not.
However, when you place birth in the hands of highly skilled professionals who do not possess the sophisticated technical skills of obstetricians and want birth to be less medical then you must have a more skilled consumer.
The hope was that ‘choice’ and ‘informed consent’ would produce those results.
Birth skills coupled with ‘choice’ can go a long way to:
• Achieve the ‘natural births’ promoted in the midwifery model.
• Positively impact births that use medical care for safety.
• Adapt to any birth as it unfolds when choices changes.
Delivery of service should not remain separated from consumer involvement which should not be based on a ‘wish list’ or ‘menu item’ mentality. This:
• puts unrealistic expectations on birth providers and feeds into the litigation model.
• maintains a unskilled, incapable and overly dependent consumer.
Many natural physiological human processes are coupled with highly refined skills. This is so common we don’t think about it. Childbirth has just been left behind.
The hope expressed in the 1990s has not eventuated … certainly not from lack of effort. Steps need to be taken now to bring all birth providers into a new alignment with families who use their service. Childbirth isunique and we can create any relationship we want. Why not create a relationship where there are designated jobs and skills: the birthing woman and her birth coach/support lack their skills while the professionals have an abundance.
Imagine what birth would look like when 85% of expectant famiilies take time in the last 3 months of pregnancy to teach themselves birth and coaching skills, come into their birth experience ready to behave well, act well, cope well and manage well the sensations of a labouring childbirth and participate in surgical deliveries? Could this image have a positive change on childbirth statistics? The statistics collected indicate this could happen when … some things have to be put into place.
We know from the Pink Kit statistics that 5 % wil not bother and actually resist. Ten to fifteen percent will say they do but don’t. That leaves 85% who already been educated to the importance of teaching themselves these skills and use them.
What actually motivates famillies? The pregnant belly getting bigger. We often hear particularly from midwives that women won’t change their life style and that is true. The PK skills are only self learned for a short time, don’t require life style change and work within all births. The skills evolved in the 1970s primarily with very conservative and often families from religious backgrounds.
So, our vision at Common Knowledge Trust is for the Maternity Service to ‘share care’ with expectant families.
