eSensitive Midwifery Magazine Issue 42 - Mar 2019 by Sister Lilian Centre

Issue 42 • March 2019

Did you know? • Holding babies impacts their genes

Halt the false information! Breastfeeding is a no-brainer

• Stem cells can be found in baby teeth • Circumcision has been linked to SIDS • Bicarb can improve labour progress

The perilous problems with plastic

• Longer breastfeeding is linked to smaller waists

On trend

Home birth – but at the midwife’s house!

Room for improvement in antenatal care By professionals and pregnant women

The evidence on inductions Midwives cannot continue to keep quiet

Complete Vacuum Delivery System

91%

92%

98%

93%

99%

96%

OA***

Position of Foetal Head

Pelvic Outlet

OP**

Pelvic Floor

OT*

Mid-Pelvis

76%

(0 to+1)

(+2 to+3)

(+4 to+5)

Station of Foetal Head

Overall Successful Completion of Birth

CONTENTS Anterior 3. New editor Margreet Wibbelink welcomes readers 4. Guest voice - Robala ka khotoso, Bra Don

Pregnancy 6. Antenatal care analysis – plenty of room for improvement 9. Insidious anxiety – help avoid outright fear or undue stress 10. Belly Talk: Damaged sperm behind multiple miscarriages • Taller women, longer pregnancies • Omega-3 to prevent prematurity • Nuchal cords not necessarily nasty • Midwives saving mothers • Promote skin-to-skin from pregnancy onwards

12. A critical eye on induction of labour – evidence shows the real risks 15. Birth review: A sad study for SA midwives • Bicarb in birth • Gut microbes: home vs hospital 16. Home birth at the midwife’s house A growing trend in South Africa

Hi there, beautiful midwives

My name is Margreet Wibbelink, aka ‘The Surfing Midwife’. It is with great excitement that I am paddling for a new wave in my life and joining Sister Lilian Centre and Sensitive Midwifery as the new General Manager and Editor. Thank you, Sister Lilian, for entrusting me with your baby – including this thriving magazine. As a passionate midwife specialist, I am ready to dive in!

Mom & Baby 18. Unpacking postnatal depression 21. First steps: Circumcision linked to SIDS • Baby acne is a thing • Postnatal mortality blame • Holding babies impacts their genes • Rather collect dental stem cells • Babies are more sensitive to pain than adults

You’ll notice we’ve got a new look, including on our websites and social media pages. We have chosen the protea, also South Africa’s national flower, as part of our new logo, because it symbolises transformation, courage, and diversity. I believe we are entering an exciting new era in midwifery, and we will need all of these qualities. Let’s enjoy the ride – and the read – together.

Breast Assurance 24. Breastfeeding is a no-brainer 27. Milky ways: Marijuana and nursing moms • Breastfeeding beyond six months linked to smaller waists • Skin-to-skin cures coma and starts lactation

Facebook Instagram Blog www.sensitivemidwifery.co.za

Dimensions 28. The problem with plastic 31. Reflections: Calendula: great ‘gateway drug’ to natural remedies • Essential Competencies for Midwifery Practice update • Mom, put down your phone

Posterior

Baby City helps make Sensitive Midwifery Magazine available to midwives for free

32. Sensitive Midwifery Symposium 2019 Programme 33. Key research references in Issue 42 35. Last word – PhD labour pain is worth it in the end!

Managing editor Sister Lilian Editor Margreet Wibbelink Sub-editor Kelly Norwood-Young, Hello Hello Contributors Ingrid Groenewald, Natasha Stadler, Sister Lilian, Margreet Wibbelink, Kelly Norwood-Young, Professor Sindiwe James Snippet research Margreet Wibbelink, Kelly Nowood-Young, Sister Lilian Business manager Alan Paramor Advertising sales Gillian Richards, Diana Twala Design Lise-Mari Coetzee, JBay Studios

Editor's Letter

Birth

TEAM Sensitive Midwifery

E: magazines@sisterlilian.co.za T: +27 12 809 3342 C: +27 71 447 3321 Fax2email +27 86 691 2485 Snailmail PO Box 11156, Silver Lakes, Pretoria, 0054

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Published by Sister Lilian Centre® No part of Sensitive Midwifery Magazine may be reproduced in any format without written consent of the publisher. All rights reserved. Every precaution has been taken to ensure correctness of information and references, but opinions expressed in the digital version of Sensitive Midwifery Magazine do not necessarily reflect standard obstetric practice, though the publishers and editorial team set

great store by ethical, responsible maternity care. While we firmly believe that the content found here will help improve midwifery and birthing, responsibility cannot be taken for the application in practice of Sensitive Midwifery Magazine’s information, tips, suggestions and guidelines. The publication is intended for the interest of midwives and related maternity professionals only. Copyright: Sister Lilian Centre®

Robala ka khotso, Bra Don A sad Sensitive Midwifery team pays tribute to colleague and friend Don Modise

tumeleng Donald Modise was loved, and will always be cherished and missed, by many – family, friends and colleagues. He was fondly known by those who cared for and respected him as either Our Uncle Don, Oompie Itumeleng, Bra Don, or Papa D.

Grown in the heart of South Africa Don was born on 14 February 1953, the second child of father Lebogang (now departed) and mother Kegomoditse Modise in Mangaung (Bloemfontein). That’s where Don spent his childhood, attended school, and made many lifelong friends. Renowned for his sporting abilities, he played softball, chess, tennis and cricket. What many don’t know is that Don received National Colours for cricket and represented the Black Springboks in the apartheid years.

A friendly, fun guy

His heart beat for NICU babies

In the words of colleague Phillipine Ngcobo, ‘Don would sing a song Sohlangana e yardini meaning, “We’ll meet at the entertainment place”. This is a Kwaito song he used to sing when he was off on his frequent holidays, especially to Durban, the city he loved so much.' That’s where he became known to Sensitive Midwifery, and where during his leave, he attended Symposium year after year, eventually becoming almost part of the team, assisting with networking and at registration. Don also attended Symposium in Johannesburg and Cape Town when the fancy took him.

Don qualified as a nurse from Bafokeng Nursing College in Rustenberg and his long, exemplary career led him from the North West Province, via Thaba ‘Nchu to the Western Cape. Don was a valued part of the Gatesville Melomed NICU team at his untimely passing. As unit manager Jackie Maart recalls, ‘Don never stayed away from work and he was always punctual. He loved playing music for the babies, especially jazz music. Don was also good with breastfeeding advice and assisting moms with latching. If a mother had engorged breasts, Don was asked to assist in the postnatal unit. He had the softest hands, which he regularly moisturised, and could express engorged breasts like no other!’ On a more personal level, Jackie remembers, ‘Don loved to cook, and would share his food with me when he made pap or samp. He had the funniest little laugh, like a naughty little boy.’

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There’s no doubt that the gaping hole he leaves in so many lives will nevertheless run over with fond memories and many a toast. Sensitive Midwifery salutes a very special colleague and wishes his family well as they come to terms with life without Bra Don.

Issue 42

Pregnancy

Antenatal care analysis

There seems to be much room for improvement in how both healthcare professionals and pregnant women conduct themselves with regards to antenatal care – midwife specialist and new editor of Sensitive Midwifery Magazine, Margreet Wibbelink, investigates

hough pregnancy and birth are natural physiological events that often need no intervention, antenatal care (ANC) is vitally important to make sure all is well with mom and baby. When care is done carefully, with thought, skill and compassion, it can prevent many complications and even maternal or newborn death. Furthermore, this is an essential time to empower and equip women for birth and beyond – and the responsibility for informing them lies with midwives.

WHO in 2016, as the perinatal death rate was not falling as intended, and it was found that too few visits resulted in missed opportunities to detect and treat asymptomatic pregnancy complications. When implemented well, BANC Plus covers all the bases for antenatal midwifery care and should prevent many complications during pregnancy and birth. Unfortunately, research reveals that implementation of BANC Plus seems not to be completely successful, revealing that many women don’t book on time, adhere to their follow-up visits or comply with their treatment.

WHO on ANC The World Health Organization (WHO) defines ANC as the care provided by skilled healthcare professionals to pregnant women and adolescent girls in order to ensure the best health conditions for both mother and baby during pregnancy. Within the continuum of reproductive health care, ANC provides a platform for important healthcare functions, such as health promotion, screening and diagnosis, and disease prevention.

Concerns among midwives have been noted in the private sector as well. There is a growing tendency towards cutting back on antenatal care because of a lack of funds. Sensitive Midwifery wonders how attendance and the experience of antenatal care by pregnant women can be improved. ‘Woman-centred care’, ‘midwife-led care’ and ‘continuous care’ are terms trending in the international midwifery world. But where did they arise, what do they really mean, and what do they have to do with antenatal care?

In the South African public sector, we first became familiar with the Basic Antenatal Care (BANC) model of six regular antenatal checks in 2008 and more recently with BANC Plus (2017). These are antenatal care guidelines drawn up by the Department of Health in accordance with WHO recommendations. BANC Plus, with a minimum of eight visits, followed a review by the

Woman-centred care This concept emerged from the women’s health movement of the 1960s and 1970s, based on feminists’ criticisms at the time. The Changing Childbirth Report Continued on page 7

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Continued on page 7

Pregnancy

then borrowed the term and applied it to maternity care. The report was commissioned by the United Kingdom Department of Health as a result of complaints by women who gave birth in public hospitals. The issues raised were particularly about a lack of continuity of care, information, involvement in decision-making, and respect and sensitivity among caregivers – all relevant to the concept of woman-centred maternity care. However, despite this, one distinct definition of womancentred care does not exist and Morgan (2015:11) suggested that, instead of a definition, this form of care should rather be described as consisting of certain characteristics, namely:

Philosophy in action ‘Woman-centred care is a philosophy and a consciously chosen tool for the care management of the childbearing woman, where the collaborative relationship between the woman and a midwife – as an individual and professional – is shaped through co-humanity, and interaction; recognizing and respecting one another’s respective fields of expertise. Woman-centred care has a dual and equal focus on the woman’s individual experience, meaning and manageability of childbearing and childbirth, as well as on the health and wellbeing of mother and child.’ Fontein-Kuipers et al., 2018:1

• individual focus • shared responsibility, reciprocity, open communication and receptiveness • empowerment • information sharing, interdependence and collaboration • participative decision-making with a known caregiver • autonomy, self-determination and self-reliance • respect: honouring culture, ethnicity and social and family background • holistic care • an atmosphere of calmness and safety Woman-centred care is best achieved by continuity of care, the recognised gold standard which most midwives wish they could attain in all spheres of practice. Continuity of care facilitates midwives’ ability to empower the women in their care throughout the perinatal period, relieving anxiety and all its deleterious knock-on effects in women, and making holistic care so much more attainable for midwives.

From concept to care reality It sounds perfect, but how feasible is it for a single midwife to give a mother that level of care? It starts with understanding the philosophy of woman-centred care. By paying attention to the explanation, healthcare professionals and midwives could be filled with great ideas and innovations as to what and how to improve

the care they provide to women. There can be no one ‘prescription’ for every setting of maternity care. Instead, individual midwives can energise their personal practice and experience the difference an individual can make! One example is American doctor Amy Crockett from South Carolina, which had one of the worst US maternal mortality rates in 2005. To improve antenatal care and therefore complications and death rates, she evolved ‘Centering Pregnancy’, where women would do their ANC visits in two-hour group appointments. Amy changed the goal of the visit to preparing women to become mothers and developed a full programme for the group antenatal care to ensure that pregnancy health checks, as well as educational imperatives, were effectively achieved. Today this model has also been implemented in other countries such as the Netherlands, and even been put to test in the Healthy Mom and Baby Clinic in the Eastern Cape town of Jeffreys Bay – with great success.

Stand up and be counted Surely there can no longer be any excuse for not addressing the rather dire maternity outcomes in South Africa? World health policy, national guidelines, South Africans’ ingenuity, midwives’ desire for change and women’s ever-increasing appeal for better care are all focused on greatly improved outcomes. All that is still needed is for every midwife to refuse to take no for an answer when they feel thwarted by outdated practices!

Pregnancy

Insidious anxiety Most women will experience some anxiety during pregnancy but sensitive midwives can ensure this doesn’t morph into outright fear or undue stress

lthough anxiety in pregnancy is often dismissed as nothing more than fear of the unknown, especially birth, it can have a direct physiological effect on the woman: evidence suggests that fear may delay the onset of labour, increase the pain the mother feels, and lead to higher rates of elective Caesarean, preor post-term delivery, low-birth-weight babies or neonatal breathing difficulties.

after watching a birth scene in a movie, it is likely that she will have misperceptions about her upcoming birth. Movies are filled with misleading birth clichés, and you may need to debunk many of these myths to put these anxieties to rest. When a woman is repeatedly told horror stories about birth, she is more likely to focus on these than the many positive possibilities. Ina May Gaskin advises that the best way to overcome this negativity is to repeatedly tell empowering and positive stories. Remind her that pregnancy is mostly a natural life experience and that women have an evolutionary instinct for birthing.

By getting to the root of the anxiety itself, midwives can help moms to have a less stressful pregnancy and achieve a better, more empowering birth experience.

Knowing the power of words Provide her with constant reassurance and encouragement and remember, a seemingly harmless comment could really change her pregnancy experience. A midwife who says, ‘Wow, you have a big baby!’ could fill a woman with terrifying images of vaginal damage and create doubt about her ability to birth naturally – when really, all the midwife meant is that her baby is developing well.

Handling a history of sexual abuse sensitively If a woman has ever been sexually abused, it will affect her entire life – including her intimate relationships, pregnancy and birth. The expectant mother’s trust in her midwife may be compromised, and yet, she needs to be able to trust you enough for you to guide her through her pregnancy and birth.

Breaking the fear cycle

If an expectant mother confides in you, don’t say anything that could be misconstrued as being judgemental or dismissive; rather admire her for her courage and ask if she has received, or would like to receive, professional counselling, which you could help her access through Rape Crisis (www.rapecrisis.org.za).

Often, repeated fear during pregnancy or of birth is linked to a fundamental distrust either of the healthcare system, or of a woman’s own body. If a mother feels that her questions aren’t empathetically and fully answered at her pregnancy consultations, either distrust grows, or she believes that something is wrong. One of the best ways to reassure a woman is to keep her fully informed, give her sufficient time to share her concerns, answer her questions honestly, and discuss her options in detail.

Focusing on the positive Pregnancy can be an extremely positive experience for women. As the person she turns to during this time, your attitude can have a direct influence on whether her birth only deepens her fears and wounds, or whether it heals and empowers her like no other experience could.

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See references on page 33

Pregnancy

Nuchal cord syndrome not necessarily nasty One in three babies has a nuchal cord and there is no compelling evidence of associated detrimental effects. The only definitive way of diagnosing a nuchal cord is via an ultrasound scan, where the neck area can be viewed from different angles. The umbilical cord is encased in a gelatinous, slippery substance called Wharton’s jelly, specifically to protect the cord and umbilical blood vessels against compressions and formation of true knots. It also doesn’t pull tighter around the neck during vaginal birth, as the uterus and placenta shrink in size and squeeze downwards to push out the baby, effectively ensuring ‘give’ in the cord. However, it’s been shown that oxytocin induction and premature rupture of membranes are far more likely to lead to cord compressions than a nuchal cord.

Damaged sperm behind multiple miscarriages Analysing the sperm of 50 men whose partners had suffered multiple miscarriages, a team of scientists at Imperial College London discovered that this sperm had twice as much DNA damage as the control group. Since the sperm also showed high levels of reactive oxygen species (which forms to protect sperm from infection, but which can also cause damage to sperm cells in high concentration), scientists are now investigating the link between miscarriage and reactive oxygen species in semen.

Peesay, M, 2012m ‘Cord around the neck syndrome’, BMC Pregnancy Childbirth, 12(Suppl 1): A6. Available: https://www.ncbi.nlm.nih.gov/pmc/articles/PMC3428673/

Preventing premature births

Boseley, S, ‘Damaged sperm could be to blame for repeated miscarriages’, 4 January 2019. Available: https://www.theguardian.com/lifeandstyle/2019/jan/04/more-maletests-needed-in-cases-of-repeated-miscarriages-uk-study

After reviewing the results of 70 studies from around the world, involving 20 000 women, a team of Australian researchers have confirmed that daily omega-3 supplementation can significantly reduce the risk of early labour. ‘The supplement should include at least 500 milligrams of the omega-3 fattyacid called DHA,’ said researcher Professor Maria Makrides, explaining that daily consumption reduced the risk of birth before 34 weeks by 42% and before 37 weeks by 11%.

Taller women have longer pregnancies A new study has assessed the correlation between maternal height and pregnancy duration. Pregnancies of mothers who are less than 165cm tall tend to be shorter than those of taller women, and babies of shorter mothers are also more likely to be born early term. On average, taller women (more than 170cm tall) also generally have longer pregnancies. This further supports the fact that a due date is merely an estimate and that women should be given adequate time to go into labour naturally before interventions are suggested.

Still, while the research outcome is conclusive, researchers are unsure exactly how omega-3 works to prevent premature birth. Professor Makrides noted that it likely ‘dampens down the potency of very powerful hormones … that often initiate premature birth … in order to extend the duration of gestation’. Dayman, I, ‘Premature births could be prevented by omega-3 consumption, Australian research confirms’, 16 November 2018. Available: https://www.abc.net.au/news/2018-11-16/omega-3-research-showslink-with-preventing-premature-births/10504952

Derraik, JGB, et al, 2016, ‘Shorter mothers have shorter pregnancies’, Journal of Obstetrics and Gynaecology, 36:1, 1–2

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Pregnancy

ALL THE GOODNESS OF A NATURAL BASE FORMULATED WITH INGREDIENTS KNOWN TO REJUVENATE, REPAIR & PROTECT.

Midwives saving mothers Midwives are crucial in the prevention of maternal deaths. The key findings of the latest Saving Mothers Report reveal that the number of South African maternal deaths continues to fall each triennium since the peak in 2009. Specifically, a reduction in HIV-infection and obstetric haemorrhage related deaths have been reported. Unfortunately, there has been no change in deaths due to hypertensive diseases in pregnancy, and there is still a way to go before safe caesarean section delivery is available to all who need it. Referral problems have been identified as a major contributor to maternal deaths, as well as too-early discharge and a lack of followup during the postnatal period. Even though a slight improvement in quality of care has been noted, there is still a general lack of knowledge and skills among healthcare workers. Well done to the Eastern Cape – the only province that managed to achieve the target set of a 20% reduction in maternal deaths form 2014–2016. Keep up the good work, midwives!

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NCCEMD (National Committee on Confidential Enquiries into Maternal Deaths), 2018, ‘Saving Mothers 2014-2016. Seventh triennial report on confidential enquiries into maternal deaths in South Africa: short report’, Pretoria, Department of Health. Available: https://www.sasog.co.za/Content/Docs/Saving_Mothers.pdf

Make this clear from pregnancy onwards If skin-to-skin care (SSC) is great for premature infants, it can certainly do something for full-term infants too! In fact, evidence supports SSC for all fullterm, healthy newborns as a standard of care. The new recommendation is to encourage and promote frequent skin-to-skin between babies and caregivers for at least 12 weeks past the due date. With multiple benefits for mother and child, Sensitive Midwifery agrees with this practice wholeheartedly! Cleveland, L, et al, 2017, ‘Systematic Review of Skin-to-Skin Care for Full-Term, Healthy Newborns’

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Birth

A critical eye on

induction of labour Midwife Ingrid Groenewald lives in Cannon Rocks in the Eastern Cape. She is also a wife, and a mom to three children – one in university, one in high school and one in Grade 1. Ingrid says, ‘As an independent midwife, I see lowrisk women throughout their pregnancies, do home- and water-births, and run healthy mom and baby clinics in our area. I am also a perinatal educator, who loves to interact with pregnant couples during their antenatal education sessions, and an IBCLC (International Board Certified Lactation Consultant). My passion is to educate, help and support breastfeeding mothers, as I do believe that most women can breastfeed with the right knowledge, support and care.’

After examining the evidence on inductions, midwives cannot continue to keep quiet about the real risks associated with this often-unnecessary procedure, says Ingrid Groenewald

women, need to keep educating and empowering women. We need to help them understand that this is their pregnancy, their birthing experience, their baby, and while some interventions are called for in particular situations, these decisions should always be based on evidence-based practice.

get to meet many expectant couples in my work as a private midwife and as I teach antenatal classes. Over the years, the one thing that really stands out for me is how often pregnant women are told that they have to be induced – for whatever reason. Many just accept this, without even pausing to question this intervention. Many of these women also then end up having a caesarean birth and/or experiencing negative feelings regarding their birth. When I talk to these mothers afterwards, it often feels to me as if they’ve never even considered that the reason for their bad birthing experience or caesarean birth might have been the induction to begin with.

A common yet drastic procedure Let’s start at the beginning and look critically at inductions. An induction of labour is the stimulation of uterine contractions prior to the onset of spontaneous labour. It is a very common procedure but it has also been described as ‘one of the most drastic ways of intervening in the natural process of pregnancy and childbirth’. The WHO estimates that 25% of all women in developed countries

This is the reason that midwives, antenatal educators, and any other health professionals working with pregnant

Continued on page 13

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Birth

now have their labours induced. This is a two- to four-fold increase within the last three decades. Though the procedure is common, this does not mean it is not problematic. As midwives, and considering the evidence, we all know that childbirth is a physiologically natural process, best left completely alone, not to be interfered with. Independent midwives see this time and time again: women who birth where they feel safe, surrounded by the people they’ve chosen to be there, women whose labour is not interfered with at all, birth really well. They often describe their labours and births as happy. Sadly, this is not how women who’ve been induced commonly experience their labours. Ultimately, labour induction is a drastic form of interference. The uterus is stimulated with medication in such a way that it starts having contractions prior to the onset of labour. Because of this interference, other interventions can easily snowball.

In the last decades, however, it has become increasingly popular to have labour induced earlier, sometimes even before 40 weeks gestation. Reasons include the availability of cervical ripening medications, a general increased use of intervention in childbirth, and an increase in the request from pregnant women to ‘end’ the pregnancy. Nowadays, many women request the intervention, mistakenly believing that it is an ‘easy way out’ or preferring to schedule their birth. The list of reasons some practitioners give for what they say are ‘necessary’ inductions can seem to go on and on too and inductions are even performed based on non-evidencebased beliefs, such as: • Baby is ‘full term’ from 38 weeks gestation and can be born safely • Pregnancy immediately becomes increasingly dangerous for the baby after the 40-week mark • Baby might be ‘too big’ for a natural birth

What does the evidence say? The real risks Some common problems inductions can cause are: • Hyper-stimulation of the uterus • Fetal distress • Slow progress of labour • Very painful labour • Postpartum haemorrhage • Failed inductions • Higher incidence of caesarean birth • Negative feelings for the mother regarding the birth • Postnatal depression (the use of syntocinon is now being linked to PND) • Death (studies have also indicated that induction can result in the death of about 1 in 10 000 women, caused by amniotic fluid embolism (AFE); research shows that 50%–70% of AFE is ‘associated’ with induction)

In 2018, a systematic review was done by the University of Copenhagen in Denmark, looking at the effect of induction of low-risk women prior to being post-term, where term is 40+ 0–6 gestational weeks, late term is 41+ 0–6 gestational weeks and post-term is only after 42 complete weeks gestation. Induction at late term (41+ 0–6) compared to post-term (42+ 0–6) was associated with: • An overall increase of caesarean birth • An increase in caesarean birth due to failure to progress • Chorioamnionitis • Labour dystocia • Precipitate labour • Uterine rupture • Decreased risk of oligohydramnios • Decreased risk of meconium-stained fluid

Why induce?

No differences were seen in:

Historically, labour inductions were performed only in situations where the mother and/or baby had pathological conditions that put them at risk, such as pre-eclampsia, intrauterine growth restrictions, and diabetes. Routine inductions were also only considered 14 days after the due date, or at 42 weeks gestation.

• Postpartum haemorrhage • Shoulder dystocia • Meconium aspiration • Five-minute Apgar score <7 • Admission to the NICU

Continued on page 14

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Birth

What about stillbirths? Stillbirth is such a potentially devastating event that once this is mentioned as a possibility to women, they immediately feel that induction of labour is their only option to keep their baby safe. Current risk rates for stillbirth close to and at term are: • At 37 gestational weeks, a 0.21% chance per 1000 births • At 38 weeks, it's 0.27% per 1000 births • At 39 weeks, it’s 0.35% per 1000 births • At 40 weeks, it’s 0.42% per 1000 births • At 41 weeks, it’s 0.61% per 1000 births • At 42 weeks, it's 1.08% per 1000 births Thus, the risk of a stillbirth does gradually increase with gestational age, and increases even more rapidly after 42 weeks. Some researchers have found that elective induction at 41 to 42 weeks may decrease the risk of stillbirth or newborn death. It is, however, thought that there would need to be as many as 328 to 410 elective inductions at 41 weeks in order to prevent one stillbirth or newborn death. This fact, together with all the other potential adverse effects of inductions, should be brought into consideration. Any conversation about elective induction should take into account the mother’s preferences, personal birth history, risk factors for stillbirth, chances of a successful induction (how ‘ripe’ the cervix is), as well as alternatives. If a healthy mother and baby are examined regularly, pregnancy can be allowed to continue to 42 weeks and beyond. Ways to encourage spontaneous term labour include the following: • Frequent sexual intercourse, as sperm contain natural prostaglandins, and orgasm may stimulate the uterus to contract • Eating spicy foods and 60–80g of dates a day • Therapies like reflexology and acupuncture • Cervical stretch and sweep

A risky routine Induction prior to post-term has shown few beneficial outcomes and several adverse outcomes, and according to the WHO, any medical intervention should only be done if the benefit of the procedure outweighs the potential harm. That is why Danish researchers adopted the policy of awaiting spontaneous onset of labour until post-term (42+ gestational weeks). They do not support routine induction in labour of low-risk women as their data showed that 70% of all pregnant women will go into spontaneous labour by 42 weeks gestation. Considering the evidence, should midwives not keep mothers and babies safe from harm by speaking up about practices that are not medically necessary? See references on page 33

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Birth

review A sad study for SA midwives

A recent study done among women in South Africa found that midwives have largely failed to act as vanguards of normal birth. Patients did not understand the role of midwives nor their professional preparation. The study also revealed that women perceive childbirth as dangerous, that technology is seen as a necessary intervention, and midwifery care is regarded a second-class, cheaper service. These beliefs are fuelled by policies and obstetrical efforts to move birth into the institutional setting. Importantly, the authors state that ‘those settings often fail to appreciate the value of physiologic birth, the importance of the midwifery model of care, and the need to integrate cultural beliefs and practices into care’. Hastings-Tolsma, et al, 2018, ‘Birth stories from South Africa: voices unheard’, Women and Birth, 31, 42–50

Birth

Bicarb in birth This easily available, low-cost treatment could reduce C-section rates and improve maternal morbidity. The field of sports medicine has long known that lactic acid can impede muscular performance, and that taking bicarbonate of soda orally before physical activity can counteract these effects. Many athletes have benefited from this knowledge, and now we know that the benefits of bicarb can be applied to birthing women too. Since the uterus is a muscle, lactic acid build-up can inhibit labour. A recent study, conducted by scientists from the University of Liverpool and the Karolinska Institute of Sweden, looked at whether oral intake of bicarbonate of soda in dystocic (slow or stalled) labours would affect amniotic fluid lactate (AFL) levels and influence the birth outcome. Promisingly, the use of bicarb (before artificial oxytocin was administered) decreased the acidity of the amniotic fluid and was associated with a 17% increase in spontaneous vaginal deliveries. Wiberg-Itzel, E, et al, 2018, ‘A randomized controlled trial of a new treatment for labor dystocia’, The Journal of Maternal-Fetal & Neonatal Medicine, 31:17, 2237-2244

Gut microbes: home vs hospital While we’ve long known that the way a baby is born affects his or her microbiome (which directly affects immunity and metabolism), a new study has revealed that where babies are born influences the microbiome too. Researchers found that babies born at home have a more diverse microbiome than those born in hospital. The results suggest that perinatal interventions, as well as the hospital environment, may affect the microbiome of the vaginal source and the initial colonisation during labour and birth. Such effects could persist in the intestinal microbiome of a baby up to one month after birth. While more research is needed, the authors recommend changing the hospital environment so it more closely reflects home conditions for low-risk births. Sensitive Midwifery also suggests encouraging home birth with a midwife! Combellick, et al, 2018, ‘Differences in the fecal microbiota of neonates born at home or in the hospital’, Scientific Reports, 8:15660

Birth

Home birth

at the midwife’s house

Creating a professional, safe, beautiful space in one’s own home to help women birth their babies is a growing trend in South Africa, and Natasha Stadler is one such pioneering midwife

Midwife Natasha Stadler

hile a midwife wishing to start a ‘birth home’ – also a growing trend in this country – will need to be prepared for all sorts of red tape, and a lengthy and arduous process, there is no legislation against home births of any kind, nor specifications given as to what is needed to birth at home or whose home women may birth in. Cape Townbased midwife Natasha calls the space she has created a ‘birth room’, where home birth takes place at her home rather than the client’s.

and what I do. They were all so excited and pleased to hear the wonderful news of healthy babes being born nearby. Since then, many babies have been born in my Womb with a View – approximately 70% of those I assist per year.

Natasha shares her story with Sensitive Midwifery Magazine readers: When I decided to become an independent midwife in 2006, I was living in a house with a separate flatlet, which is where I consulted with my antenatal clients. Before long, some clients asked me if it would be possible to have their babies at my house – which it was. This was easy for me as I did not have to drive anywhere and I didn’t require much more than what I already needed for a normal home birth.

Cleaning up everything after birth at my home, and cancelling the next day's appointments because the space has been in use, is not my favourite part – but I do get a good rest after every birth.

Creating my ‘Womb with a View’

I am truly grateful that it was possible to create my ‘Womb with a View’. Many wonderful births have happened here and I am happy to hold a peaceful space for labouring women. Whereas others my age are starting to talk about retirement, I don’t plan to retire and look forward to continuing to welcome new babies in the familiar comfort of my own home, for as long as I can.

Pitfalls and plusses I sometimes miss the quiet drives on my way to a client’s house, tiptoeing into their home, trying not to wake anyone, being greeted by the family cat or dog. It always made me feel a bit like Santa!

I enjoy that I have all my birthing gear around me; I know where the plug sockets are, how much hot water I have, etc. While waiting, I can rest in my own bed, use my own kitchen, and I am near my children.

Later, when I moved to another house, I converted an old trophy room into my new birth room, and so the ‘Man Cave’ became what I called my ‘Womb with a View’. To avoid any complaints or strange assumptions, I made sure I visited all my neighbours to inform them about who I am

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Birth

Setting up your own space The layout of your own birth room will depend on your space, preference and needs. However, if you wish to allow clients to birth from your own birth room, it’s essential to have appealing, hygienic, accessible amenities, and there are also quite a few practical things to consider: Registrations and policies • Your registration with SANC must be up to date • You need indemnity insurance: there is a range of companies who offer indemnity insurance and you should see which suits you • To claim from medical aid schemes, you will need a practice number, which you can obtain by registering with the Board of Health Funders • You should sign an agreement with a medical waste company to collect the placentas and fetch any sharps you may have used Equipment and consumables The medical equipment you need would be the same as for a home birth: fetal Doppler, observation equipment (BP monitor, thermometer, urine sticks, etc.), sterile instruments, suture materials, IV therapy, urinary catheter, oxygen, infant suction, emergency supplies (thermal blanket, airways, laryngoscope) and possibly medication. These can be obtained from various surgical supply and pharmaceutical companies. I get the consumables from a pharmacy so I don’t have to buy too much at one time. Should you run a clinic as well, you might benefit from a prescription licence, or assistance from a partnering doctor.

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Mom & Baby

Unpacking

postnatal depression Maternity health professionals can help avert postnatal depression, writes Sister Lilian

Happily, maternal adaptation to the new hormonal (and social) status often stops at the common thirdday blues, which passes within a few days for most. In others, the reaction can progressively become stronger and for some, the depression only starts weeks or months later, when the birth itself is all but forgotten. PND is real – a woman cannot just ‘pull herself together’ because it is ‘just her hormones’.

epression is characterised by at least a twoweek period of sustained low mood (for most of the day, nearly every day). This includes loss of interest in pleasurable activities, profound feelings of guilt and hopelessness, and at worst, suicidal thoughts. Postnatal depression (PND) is defined as ‘depression suffered by a mother following childbirth, typically arising from a combination of hormonal changes, psychological adjustment to motherhood, and fatigue’. It can develop at any stage during the first year after a baby’s birth and has been known to persist well into the second year of motherhood. A woman is incredibly vulnerable after giving birth and sometimes a combination of too many stress factors at this time can trigger depression.

The truth is that the physiological ebb and flow of pregnancy, birth and postnatal hormones are often tampered with in ways that make women more liable to ‘hormonal’ PND. For instance, PND often follows an emotionally or physically traumatic birth (fear is a prominent endocrine disruptor), synthetic hormone induction or augmentation (inhibiting natural hormone production), and the use of opiate pain medication (usurping the body’s inherent hormonal pain regulators).

Not ‘just’ her hormones

Continued on page 19

There is no single cause of PND; mostly, a combination of factors contribute to the symptoms individual women experience. And yet, how often haven’t midwives heard – maybe even themselves said – that the baby blues and the more serious PND are ‘just the adjustment of the hormones after birth’, often dismissing the causes and implications of the very real link between the endocrine system and PND?

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Mom & Baby

Maternal micronutrient imbalance Second only to ‘hormonal adjustment’ in the blame stakes, is maternal micronutrient (‘chemical’) imbalance or deficiency. Important vitamins and minerals might well be depleted at the conclusion of a pregnancy, and after the efforts of birth. Zinc, for instance, contributes to a sense of mental and physical well-being, and stress and depression often react favourably to zinc supplementation. Sufficient calcium and magnesium are also very necessary in the postnatal period, as is the vitamin B range. Blood loss during and after the birth can lead to anaemia and its bedfellows: tiredness, listlessness and depression, if it has been severe. Although the body will usually soon correct this condition of its own accord, women experiencing these symptoms should have their haemaglobin levels tested at their six-week postpartum check-up and if not within acceptable values, increase their dietary iron intake, take the tissue salts Calc phos, Ferrum phos and Nat mur, and if the anaemia is more severe, take iron supplements.

Joining the social dots There are a number of contributory factors to PND which, although they are often spoken about as challenges for new mothers, are not fully understood for their link to the symptoms of depression. They include these four:

3. Crying baby. Colicky or ill babies often cry incessantly and this can wear down the hardiest of mother’s reserves, actively contributing to poor coping and possible depression. There is obviously no easy answer if a baby is ill, but for women who are given supportive and natural coping strategies for dealing with crying and colic, coping and emotional adjustment improve remarkably. Teaching mothers to respond to baby-led feeding and sleeping cues, and babies’ emotional needs is key. Encouraging new mothers to go on outings with other moms and their babies, and to take occasional ‘mom-time’ works well too, as babies relax when sensing their mothers doing so too. 4. Relationship strain. Unresolved problems in a marriage or committed partnership can form a fertile base for postnatal depression. Babies don’t save poor relationships and mostly the added challenges see the wheels come off. Communication needs to be good so that both partners more readily understand what the other is experiencing after Baby has joined the family. Although already a little late, this should be addressed in antenatal classes, to encourage couples to face up to and hopefully solve any such issues.

A predisposition to PND

1. Tiredness. Exhaustion is common to most new moms, but certainly some react even more negatively than others. Babies’ sleep requirements are unfortunately not always predictable and sleep deprivation is a frequent complaint if moms reject the practical and emotional solution of co-sleeping.

Unfortunately, women might be more prone to postnatal depression if there is a history of depression before or during pregnancy. Although some maintain that risks of not using antidepressants in pregnancy and while breastfeeding are too severe, most antidepressant medication is best avoided. Counselling is essential for these women and they should be encouraged to take a homeopathic depression remedy to help them cope better during pregnancy and after birth, and to help avert major depression from developing.

2. False expectations. If women are disappointed or traumatised by their birth experiences and their immediate experience of motherhood, signs of depression may well follow. Women who are used to efficiently running their personal and work lives, and think that they need to continue in this vein, frequently think of themselves as having failed when these methods don’t work with a baby-orientated lifestyle. Low self-esteem soon follows – a recognised characteristic of depression.

Lots of love, support, tenderness, understanding and real practical help after the birth of a baby from a woman’s partner, close friends and family members is also very important. Suggest that she be allowed to sleep in once or twice each week as this often restores her physically, mentally and emotionally. Skin-to-skin contact, even if a depressed mother is inclined to avoid it, can be a hugely therapeutic measure for her, as much research now confirms. Continued on page 20

Everything you need from South Africa’s leading baby hyper.

Mom & Baby

Did you know? • Depression affects 10–20% of women worldwide. • The incidence of postnatal depression is higher amongst mothers with babies in NICU, where post-traumatic stress syndrome complicates the challenges they face. • A recent study discovered that women who received Lactobacillus rhamnosus (HN001) during pregnancy and the postpartum period, had significantly lower postnatal depression and anxiety. • New dads too can suffer from postnatal depression. If Dad seems to be withdrawing, disappears for long spells, or has changed personality, this is what might be the problem. • The common and partially physiological inflammatory responses in the last trimester of pregnancy and the postpartum period, may be further aggravated by birth trauma, sleep disturbance, postpartum pain and psychological stress, putting a new mother at greater risk of postnatal depression.

PND prevention and treatment Medication is an option, but it would almost seem unethical of midwives not to advise women of all the many other treatment strategies available to them, seeing as less medical and more natural, supportive and informational approaches are the authentic midwifery way. For instance, share some of the ideas in this article, refer her for professional counselling, suggest group ‘treatment’ and support strategies, advise on homeopathy and carefully selected herbal remedies, or suggest the use of acupuncture. However, the old mantra of prevention being better than cure is of just as much consequence. It’s within every midwife’s scope of practice and her advocacy role to acknowledge and act on the connection between good pregnancy and birth care, and lowered risk of postnatal depression. Alleviating anxiety about birth in pregnancy (see page 9), protecting from unnecessary medical intervention in physiological birth, and advocating for an expectant third stage are all the midwifery way of helping to prevent PND, amongst many other poor outcomes. Encourage mothers after birth, reminding them that postnatal challenges don't last forever. Keep a watchful eye for signs of PND and make timeous, emotionally astute, practical suggestions. If you, the midwife, values the importance of the mothering role, the mothers will pick up on this and self-esteem and profoundly positive confidence will grow, and PND will be less likely. See references on page 33

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Mom & Baby

Baby acne is a thing Circumcision linked to SIDS A UK study by Dr Eran Elhaik from the University of Sheffield has suggested a strong correlation between male neonatal circumcision (MNC) and sudden infant death syndrome (SIDS). Examining latitudinal SIDS and MNC data (from 1999–2016) from 15 different countries, where postmortem examination of infants had been conducted, the study concluded that MNC is a major risk factor for SIDS. Dr Elhaik noted that an infant loses a lot of blood as a result of circumcision – ‘the equivalent of two to four blood donations for an adult’ – and as a result, ‘the blood pressure drops and the heart has to work harder, which can result in a heart attack particularly for infants whose heart did not finish developing or has some other defects’. Not only are SIDS rates high in countries where MNC rates are currently high, but this link may also explain why, historically, SIDS has affected particular populations more than others. Dr Elhaik gave the example of 16th-century Israel, where Jews blamed infant deaths on a Babylonian goddess called Lilith, the killer of infant males. Now, the evidence points to early circumcision as an explanation for these deaths. Of course, early circumcision is not the cause of all SIDSrelated deaths and more research is needed in this area, but with MNC being a major risk factor, parents and practitioners should reconsider this practice. O’Callaghan, J, ‘Early Circumcision May Be A Major Cause Of Sudden Infant Death Syndrome’, 31 July 2018. Available: https://www.iflscience.com/health-and-medicine/early-circumcisionmay-be-a-major-cause-of-sudden-infant-death-syndrome/

Milia (often called baby acne or ‘babasuur’ in Afrikaans) is the yellow-white pimply rash, which so many newborn babies develop over the bridge of the nose and the cheeks at about two to four weeks of life. The pores in this area become blocked until the skin function matures. Milia is not serious and generally resolves spontaneously by three months. No specific treatment is needed but offer moms healthy alternative tips to cortisone creams, like: Do not squeeze the pimples; rinse the area with cooled rooibos tea; give Baby a calendula-based homeopathic remedy and apply a light layer of calendula cream. Remember too that the skin is an excretory organ, and often reflects an unhealthy diet. Breastfeed rather than giving formula milk. A breastfeeding mom should reduce or avoid refined, animal proteinrich, processed, additive-rich foods. Dairy and grain products, and processed meats are common triggers in babies being weaned onto foods, so give Baby more fruit and veg.

Postnatal mortality blame Approximately 20% of maternal deaths in South Africa occur outside of healthcare facilities, from causes similar to those of maternal deaths in facilities. Since 96% of women in South Africa deliver in healthcare facilities, most of the women who die outside of facilities are either discharged too early or develop complications later. Obstet Gynecol Neonatal Nurs, 46(6), 857–869

Mom & Baby

steps

Rather collect dental stem cells While some parents are forgoing the huge benefits of optimal cord clamping in order to collect and store umbilical cord blood, there is now another way to harvest stem cells that can be used to regenerate bone and tissue in other parts of the body. Scientists have discovered that dental stem cells (called mesenchymal stem cells) can be harvested from the dental pulp within baby teeth, wisdom teeth, and healthy permanent molars. After a tooth is removed by a dentist, the cells can be extracted from the dental pulp and then cryogenically frozen. Research is ongoing but applications include treatments for certain cancers (leukemia, lymphoma), multiple sclerosis, Alzheimer’s, Type 1 diabetes, stroke, Parkinson’s, muscular dystrophy, bone loss, cardiovascular disease, and neural injuries. Care.com, ‘Why You Should Save Your Child’s Baby Teeth’, 28 June 2017. Available: https://www.care.com/c/stories/11229/why-youshould-save-your-childs-baby-teeth/

Babies are more sensitive to pain than adults Holding babies impacts their genes New research from the University of British Columbia and BC Children’s Hospital Research Institute has shown that the molecular profile in the cells of children who were distressed as babies and received less physical contact, was underdeveloped for their age. ‘We plan to follow up on whether the “biological immaturity” we saw in these children carries broad implications for their health, especially their psychological development,’ said lead author Sarah Moore, noting that it would ‘underscore the importance of providing physical contact, especially for distressed infants’. UBC Faculty of Medicine, ‘Holding infants – or not – can leave traces on their genes’, 27 November 2017. Available: https://www.med.ubc. ca/holding-infants-or-not-can-leave-traces-on-their-genes/

It is a commonly held, albeit mistaken, belief that babies’ nervous systems are not developed enough for them to feel pain. As a result, babies are often subjected to painful procedures without pain relief. Now, a pioneering study has shown that babies not only experience pain, but that they have a lower pain threshold than adults. Oxford University researchers compared MRI scans of infants to adults, all of whom had been exposed to the same pain stimulus (a poke on the sole of the foot) during a brain scan. Of the 20 pain regions active in adult brains, 18 were active in babies experiencing pain. Furthermore, babies’ brains had the same response to a weak poke as an adult brain had to a stimulus four times stronger, indicating that infants experience pain more intensely than adults do. University of Oxford, ‘Babies feel pain “like adults”’, 21 April 2015. Available: http://www.ox.ac.uk/news/2015-04-21-babies-feel-pain-adults

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Breast assurance

Breastfeeding is a no-brainer The interruption of intuitive breastfeeding ranks high on the list of harms perpetrated in the name of maternity care, says Sister Lilian

away once the realisation of wrongness sinks in) under the guise of modern, ‘evidence-based’ care. Iatrogenesis has long been a concept; it’s almost turned into a martyr-like situation, with the collateral harm caused ‘in treating the problem for the greater good’ seldom exposed to intensive scrutiny. However, that’s only one side of the sad story – another frightening part is how perfectly functional physiological body processes are undermined by the medical world. That’s why this topic is under discussion in the ‘Breast assurance’ section of this edition of Sensitive Midwifery Magazine – it’s time to bravely face that truth!

here’s no hiding away from the truth nowadays. In the information age, those who wish to know, can! It may take some digging, but somewhere there will be a trail that gives insight into how today’s status quo was influenced by the past, how current trends arose from yesterday’s actions (or ashes), and how past policies and protocols have left a predatory pawprint on many a perfectly natural phenomenon. Clouding the knowing of the truth, though, is an abundance of false information – it’s a bit like entering a maze with many dead-ends. Symbolically, walking a maze is said to enlighten and clear the senses of red herrings, allowing for transformation and keen insight. If you’re in it to achieve greater understanding, in order for you to offer authentic answers to those you help, your persistence will pay off.

It’s time for a reality check Did lactation consultation become a thing because a modern medical world discovered that breastfeeding a baby was something that sorely needed professional advice – or did the medical world make breastfeeding more difficult with misinformation and then have to find a ‘solution’?

What’s with the philosophising? Well, this is probably one of the most important things that today’s (Western) health professionals need to ponder and embrace, because so much harm has been done (and squirrelled

Reflect for a moment on how new mothers managed to breastfeed successfully before the Continued on page 25

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Breast assurance

advent of lactation consulting as a profession – or are you of the mistaken opinion that they didn’t? Without any real possibility of an alternative, the mother’s own milk, direct from source, was normal and ungoverned by anything other than perfect demand and supply physiology. Some challenges would have and did arise, but experienced mothers were willing and able to advise and support their younger sisters. As with so many things in life, if the expectation is one of success, success will be the result. The more breastfeeding was analysed, medicalised and masculinised, the less ‘normal’ it became. How sad that something as wonderful and instinctive as nursing a baby became seen as unsophisticated, and breast milk as of no greater benefit than adapted cow’s milk. Intuitively, there is very little room to dispute the success and ease with which the vast majority of mothers breastfed a few generations ago – there’s historical, sociological, literary, artistic and anthropological evidence aplenty. Not that this stops researchers and those with a scientific bent from questioning its validity! They’ll concentrate on historical reports of milk fever and point to perinatal morbidity and mortality rates to prove the need for a medical approach to solving public health dilemmas of indigenous, poorly resourced (referring to Western health resourcing, of course!) and rural communities. Somehow, the impact of industrialisation and the price of medical ‘advancement’ as a huge part of the problem is glossed over!

One thing leads to another Almost two decades into the 21st century, when neuroscience and other fields of study are showering us with evidence that many physiological body processes, inherent endocrinology and intuition provide an incontestable and potent blueprint for the most effective preventative and holistic health we could hope to achieve, the medical world often

continues to intervene with what they consider technologically and medically superior methods. In maternity care, it all begins with the approach to pregnancy and birth. Women’s instinctive ability to birth has been so undermined that very few believe it’s possible to do so safely outside of the medicalised way – despite evidence to the contrary. The knock-on effect of this is disempowered breastfeeding intuition and physiology. Then, there is of course a need for help for nursing mothers and their babies, but that doesn’t mean that the root cause shouldn’t be exposed and ‘treated’ by returning to the inherently successful breastfeeding blueprint. Before taking a closer look at what that may be, we need to briefly evaluate the medical approach to ‘breastfeeding problems’. The original ‘sin’ was to come up with protocols and guidelines for how mothers should feed on a schedule, and restrict or force feeds – all in the name of more civilised, modern routines. The many cases of engorgement, cracked nipples, mastitis and breast abscesses that followed called for medical treatment or guidelines that further hijacked physiology and intuition. The rise and consequences of the formula milk industry needs no further mention in this article, other than to point out that commerce in fact provided answers to a need that arose due to a problem caused by ‘health’ professions – it’s rather hypocritical to point fingers only at manufacturers of artificial milk. The more breastfeeding ‘problems’ there were, the more fertile were the grounds for the rise of a new profession – lactation consultation! Great, but still not getting to the root cause! Also of concern is that lactation consultants’ training is to a large extent of a theoretical and medical nature and consequently often rather ‘cerebral’ in nature, when nursing success is much more likely if those ancient physiological, endocrinological and intuitive processes are respected. Continued on page 26

25 High cy Poten ins m a B-Vit inc Z with

Breast assurance

See how policies change The Department of Health’s 2013 Infant and Young Child Feeding (IYCF) policy recommendation on the duration of breastfeeding for HIV-infected women was amended on 7 June 2017 to align with the updated 2016 WHO/ UNICEF guidelines: no longer should HIV-infected women be advised to stop breastfeeding at 12 months, as they previously were. The latest evidence is that these babies are in dire need of the benefits of nursing and mother’s milk. Instead, HIV-infected women who are breastfeeding – while importantly still being advised and helped to adhere to antiretroviral therapy (ART) – should be counselled and supported to exclusively breastfeed their infants for the first six months of life, to introduce complementary foods thereafter, and to continue breastfeeding for at least two years. While this is a huge step in the right direction, we’re still nowhere close to HIV-infected women being confident in breastfeeding and there’s no telling when the harm and impact of stigma and previous policies will be reversed (if ever). It also serves to point out that policies aren’t always correct and that the impact of distrusting Mother Nature’s ways should be contemplated well in advance of formulating policies.

Finding a way forward This is not to say that it’s not helpful to study more about lactation and breastfeeding. However, it’s so easy to fall into the trap of overwhelming a new mother with information and overloading her with facts and figures, to which the instinctive brain doesn’t respond well. Unfortunately, medical professionals often find it difficult to play more of a catalyst role, they themselves possibly not totally comfortable with de-medicalising mothering tasks like nursing a baby. Take heart though – trusting that breastfeeding will work once Mom and Baby get going does becomes easier with practice. This means that if midwives, lactation consultants, postnatal nurses (and doctors) are to be authentic allies and advisors of breastfeeding women and babies, they primarily need to: • Wholeheartedly believe that breastfeeding isn’t a difficult medical process but a truly instinctive, physiological one • Question and change the medical mindset that has landed birth and breastfeeding in such a pickle • Know that encouragement is the most important ‘advice’ • Ensure a protected, more silent space for nursing mothers in the first days so that breastfeeding can unfold as Mother Nature intended, just as the same applies to birthing women • Refer mothers to the La Leche League, which has truly perfected the art of breastfeeding support Birth and breastfeeding can be such empowering experiences for women! Let’s not disempower them with a misplaced feeling of professional power, fortified only by theoretical knowledge.

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Breast assurance

Milky

ways

Marijuana and nursing moms In late 2018, the Constitutional Court of South Africa legalised the use and private cultivation of marijuana, although how much marijuana a person may use in private and the age restriction for use are still to be decided. Notably, it is also still illegal to sell marijuana to others or smoke it outside of your own home. With studies having shown an increased rate of marijuana use among women, the American Academy of Pediatrics concludes in their first-ever released guidelines, that pregnant and breastfeeding women should completely avoid the use of marijuana in any form, as there is a lack of safety data regarding the possible effects. Sensitive Midwifery notes that substance use and abuse have frequently been linked to deleterious effects on unborn and breastfed babies. Midwives should counsel women with this in mind.

Skin-to-skin cures coma and starts lactation A mom in Brazil surprised her medical team when she awoke from a 23-day coma as her newborn baby was placed on her chest. The idea came to ICU nurse Fabíola Sá, who suggested that Amanda da Silva and her baby son be put together before her doctors sent her to another health facility for long-term remedial care.

Ryan, SA, et al, 2018, ‘Marijuana use during pregnancy and breastfeeding: implications for neonatal and childhood outcomes’, American Academy of Pediatrics, 142(3): e20181889

Amanda had suffered an acute epileptic seizure at 37 weeks pregnant, and her baby had been delivered via emergency c-section while she was under sedation. Due to further complications, Amanda was then placed in a medically induced coma, without having had any contact with her baby. Three weeks later, though doctors had tried to bring her out of the coma, Amanda remained non-responsive.

Breastfeeding beyond six months linked to smaller waists One recent study involving 678 women, seven to ten years after delivery, has examined the relationship between duration of breastfeeding and maternal central adiposity. Measuring waist circumference and documenting how long each woman had breastfed, researchers discovered that breastfeeding for more than six months was independently associated with a smaller waist circumference in the decade after delivery. Further research that considers lifetime breastfeeding duration is needed in order to determine how breastfeeding may influence maternal central adiposity and whether there is a cumulative effect.

When nurse Fabíola placed the baby skin-to-skin on the mother’s chest, wrapping her arms around him, Amanda began to cry; her heart rate quickened and she started lactating. ‘Her response was immediate. After 23 days in a coma her reaction was inexplicable,’ recalled the nurse, who went on to say: ‘We don’t have a scientific answer to what happened but it’s evident we should never underestimate the importance of skin-to-skin contact between mother and child.’ Parent24, ‘Mom reveals incredible moment she woke up from threeweek coma at the touch of her newborn’, 22 October 2018. Available: https://www.parent24.com/Baby/Newborn/mom-reveals-incrediblemoment-she-woke-up-from-three-week-coma-at-the-touch-of-hernewborn-20181019

Snyder, G, et al, 2018, ‘Breastfeeding Greater Than 6 Months Is Associated with Smaller Maternal Waist Circumference Up to One Decade After Delivery’, Journal of Women's Health. Available: https://www.liebertpub.com/doi/10.1089/jwh.2018.7393

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Dimensions

The problem

with plastic

Though plastic is a part of our everyday lives, it poses significant risks, explains Sensitive Midwifery Magazine writer Kelly Norwood-Young

ook around your home or workplace and it won’t take you long to spot something plastic. Whether it’s bags, food containers, utensils, cups, bottles, toothbrushes, bath mats, shower curtains, toys, or packaging, it’s apparent that plastic products are everywhere. In fact, according to WWF (the World Wide Fund for Nature), South Africans use between 30 and 50kg of plastic a year.

BPA (Bisphenol-A) is a synthetic compound that has been used to make certain plastics since the 1950s. It is commonly used in plastic for baby bottles and food containers, as well as epoxy resins, which line tinned food to prevent the metal from corroding. BPA in the body interferes with natural hormones, affecting tissue function, metabolism, mood, growth and development, fertility and sexual function.

The problem with plastic use is that it comes with both environmental and health risks. Not only do plastics (most of which are made from petroleum, which is nonrenewable) cause unnecessary waste, but using plastics while cooking or to store food can be bad for human health as dangerous chemicals are released.

In one study, the Centers for Disease Control found that 95% of urine samples contained some amount of BPA. Risks of exposure include: • Chromosomal errors in a developing fetus, causing genetic damage and spontaneous miscarriages • Early puberty • Obesity • Infertility in males and females • Changes in gender-specific behaviour • Thyroid dysfunction • Altered immune system • Cancer (breast cancer and prostate cancer) • Heart disease • Behavioural issues, such as hyperactivity, impaired learning and increased aggressiveness

Perilous plastics Between 2000 and 2018, more plastic was produced than in the whole of the 20th century, according to WWF. While approximately half of plastic waste ends up in landfills (taking hundreds of years to break down), the rest ultimately lands up in the ocean, where it causes pollution, enters the food chain and damages marine ecosystems. Not only are toxic chemicals released during the plastic production process, causing air pollution, but often, the plastic itself contains toxins that can adversely affect our health. The most common culprits are chemicals that are endocrine disruptors, such as phthalates and BPA.

But importantly, ‘BPA-free’ does not mean that the plastic is safe. In fact, BPS (Bisphenol-S, a known endocrine disrupter, with many of the same risks) often replaces BPA in polycarbonate plastics. Other plastics can be harmful too. Continued on page 29

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Dimensions

Know your plastic

Styrene, which leaches from polystyrene plastic, can negatively affect red blood cells, as well as the kidneys, liver and stomach.

The following polymer codes on plastic products are used to identify various plastics for recycling. These are international codes, which, if you know about the seven different types of plastics, can also be used to identify whether a plastic product should be used with caution or avoided at all costs.

7. Miscellaneous plastic – usually polycarbonate but also includes polyctide, acrylic, acrylonitrile butadiene, styrene, fiberglass, and nylon, and new bio-based plastics. Polycarbonate is used to make most plastic baby bottles, clear plastic sippy cups, sports water bottles, and eye glasses.

Products carrying the codes 1, 2, 4 and 5 are considered somewhat safer choices for food and beverages, whereas 3, 6 and 7 can have more harmful effects on health (except for bio-based plastics, which are also classified as 7 and considered safe).

1. Polyethylene Terephthalate (PETE or PET), used in water and soft drink bottles, medicine jars, mouthwash bottles, and containers for condiments (e.g. nut butters and mayonnaise).

It’s tricky to know exactly which toxins you’ll find in plastics carrying the 7 code, but these will often contain endocrine disruptors BPA and/or BPS.

Power over plastics So, how do you reduce your exposure, take back control of plastic in your everyday life, and help create a safer environment for the next generation? Of course, the first step is to be aware of the dangers of plastic in the first place.

2. High-Density Polyethylene (HDPE), used in milk bottles, water bottles, juice bottles, shampoo and conditioner bottles, detergent containers, grocery bags, rubbish bags, cereal box liners, and toys.

Here are a few other helpful tips: • Choose clear, silicone teats for baby bottles and pacifiers, and avoid latex rubber which can leach carcinogenic nitrosamines

3. Polyvinyl Chloride (PVC), used in children’s play mats, plastic toys, lunch boxes, table cloths and blister packs (i.e. for medications), cling wrap, plastic cooking oil bottles, sandwich bags, and clear food packaging.

• Invest in cloth nappies and cut back on disposable diaper use • When possible, use glass bottles (a silicon sleeve can protect against breakages)

PVC is the least recyclable plastic, and contains numerous toxic chemicals, including lead and a phthalate called DEHP, which studies have shown can cause males of a species to become more feminine. Many PVC products also contain DEHA, a plastic softener (e.g. used in cling wrap), which is associated with negative effects on the liver, spleen, kidneys, bones, and body weight.

• If Baby only takes a polycarbonate plastic bottle, discard it when the plastic shows signs of wear (e.g. a cloudy appearance or scratches) as old plastic leaches chemicals more easily • Carry reusable water bottles when out-and-about • Use reusable shopping bags • Store leftovers in glass containers

4. Low-Density Polyethylene (LDPE), used for beverage cups, squeezable bottles (e.g. for honey or mustard), as well as bags for frozen vegetables, bread and toilet paper.

• Cut back on plastic straws by using a plastic-free straw (or skip the straw) • As chemicals are released from plastic when heated, don’t microwave food in plastic containers and don’t cover food with plastic to avoid splattering – rather cover with a paper towel or wax paper

5. Polypropylene (PP), used to make plastic diapers, Tupperware, straws, yoghurt containers, medicine bottles, bottle caps, and disposable cups and plates.

• Be mindful of what things are made of when doing craft activities with kids (glitter, tinsel and other shiny things are often made of plastic) • Buy refills for washing and bath products and decant into reusable bottles

6. Polystyrene or Styrofoam (PS), used in disposable cups, takeaway containers, plastic cutlery, packing foam, and egg cartons.

• If plastics aren’t identified on the packaging, rather avoid the product Continued on page 30

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Plastics and childbirth The use of plastic has become so commonplace that many healthcare workers may not even notice how much plastic they use on a day-to-day basis. In his book, Childbirth in the Age of Plastics, Michel Odent explores just how pervasive plastic has become and how much it has impacted the medical industry. From the use of plastic catheters to deliver drugs intravenously or via epidurals, to plastic endoscopes being used in surgeries, medical history has undoubtedly been influenced by the development of plastics. While it would be difficult for practitioners to do away with plastic completely, Sensitive Midwifery encourages midwives to question how much plastic is truly needed during a natural birth. Independent midwives attending home births, for instance, could suggest that clients use a glass container – rather than a plastic tub – for the placenta, and more towels could be used, rather than using plastic on the floor or bed. One experienced midwife in the Eastern Cape shares her thoughts: ‘As midwives, we become so accustomed to using plastics in all their different forms, just because they are available. However, it would be so much better for our health and the health of the mothers and babies and for the environment if we reverted to a more simple, natural method of bringing babies into the world. Simplicity is often the answer. This is how we can reduce the use of plastics in our environment. Home births and natural births are very good for the environment.’ She goes on to share how home births she has attended have needed very little: ‘We had towels and we had water cloths, cord clamps. We just let nature take its course. No drips, no catheters, no needles. For the placenta, we used an empty tin. I was amazed at how few resources you actually need … It makes you think about the simplicity of nature. You don’t need any fancy wrappings or plastics or needles.’ See references on page 33

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Essential Competencies for Midwifery Practice update

Calendula: great ‘gateway drug’ to natural remedies

The International Confederation of Midwives recently released an updated ‘Essential Competencies for Midwifery Practice’. With research that is ever-evolving, it is exciting to be part of an international body that keeps revising the midwifery profession's guidance documents. Click below to see the latest guide.

Calendula is an edible flower that is highly regarded in the botanical remedies world, and has many uses for midwives. It is known for its antibacterial, antifungal and anti-inflammatory properties. Dr Eric Zielinski goes so far as to state that it is an excellent ‘gateway drug’ into natural remedies. The dried petals can be used in poultices for bumps, bites and scrapes; oil extracts can be made into healing balms, and essential oil can be added to sprays, balms and other preparations.

ICM, 2018, ‘Essential Competencies for Midwifery Practice. Available: https://www.internationalmidwives.org/assets/files/generalfiles/2018/10/poster-icm-competencies---english_final_oct-2018.pdf

Zielinski, E, 2018, ‘Calendula uses & benefits: calm, soothe and heal’. Available: https://naturallivingfamily.com/calendula-uses-and-benefits/

Mom, put down your phone Before six months of age, babies cannot recognise their mothers from a profile view, new research has found. While adults and children can identify faces from both frontal and profile views, this is not true for newborns. As Dr Hiroko Ichikawa from Tokyo University of Science explains, ‘The brain activity of babies tells us if they recognize a face because babies' hemodynamic responses in the right occipitotemporal area increase when they are viewing a face. In this study, we found that hemodynamic responses to profile faces were weak at 3 months of age, but increased more during the period from 3 to 8 months of age compared with those of frontal faces. Linear regression analysis showed that around 5.5 months of age, babies gradually recognize the profile face.’ Although further research is needed, this could have implications for postpartum bonding and attachment, particularly as mobile phone use is so prevalent. Of course, caregivers should always look into a baby’s face when communicating, but this is especially important in the first six months. Chuo University, ‘Mom, I can't recognize your face from profile view!’, 6 December 2018. Available: www.sciencedaily.com/releases/2018/12/181206115945.htm

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WORKSHOP: Natural birth – the authentic midwifery way • Theoretical foundation Definitions and evidence | Monitoring and evidence Birth anatomy and endocrinology, the benefits of physiological birth, and mobilisation during labour and birth • Delegate participation & practical Supine problems and upright objections How to make a hospital unit more physiological birth-friendly • Doctor’s message

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Antenatal care analysis – page 6 • De Labrusse, C, et al, 2016, ‘Patientcentered care in maternity services: A critical appraisal and synthesis of the literature’, Women’s Health Issues, 26(1), 100–109 • DoH (Department of Health), 2017, Improving antenatal care in South Africa. [Pdf]. Available: http://www.health.gov.za • Hofmeyr, GJ, et al, 2015, ‘Time for “basic antenatal care plus” in South Africa?’, The South African Medical Journal, 105(11), 902–903 • Fontein-Kuipers, Y, et al, 2018, ‘Womancentred care 2.0: Bringing the concept into focus’, European Journal of Midwifery, 2(5), 1–12 • Kliff, S, ‘Sit in a circle. Talk to other pregnant women. Save your baby’s life?’. Available: https://www.vox.com/futureperfect/2018/11/2/18040070/infantmortality-south-carolina-amy-crockett • Moodley, J, et al, 2018, ‘Improvements in maternal mortality in South Africa’, South African Medical Journal, 3(1), 4–8 • Morgan, L, 2015, ‘Conceptualizing womancentred care in midwifery’, Canadian Journal of Midwifery Research and Practice, 14(1), 8–15 • Patience, NTS, et al, 2016, ‘Evidence of application of the basic antenatal care principles of good care and guidelines in pregnant women’s antenatal care records’, African Journal of Primary Health Care & Family Medicine, 8(2), 1016–1022 • WHO (World Health Organization), 2016c, WHO recommendations on antenatal care for a positive pregnancy experience. [Pdf]. Available: http://apps.who.int Insidious anxiety – page 9 • Gaskin, IM, 2003, Ina May’s Guide to Childbirth, Bantam Books, New York • Heli, S, 2009, Confident Birth, Pinter & Martin, London A critical eye on inductions – page 12 • Cohain, JS, 2018. ‘More Evidence to Avoid Hospital Birth: A Critique of the Results of the ARRIVE Study’, Midwifery Today • Deckker, R, 2017, ‘Evidence on: Due dates’. Available: https://evidencebasedbirth.com/ evidence-on-inducing-labor-for-goingpast-your-due-date/ • Dekker, R, 2018, ‘Evidence on: The ARRIVE trial’. Available: https://evidencebasedbirth.

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com/wp-content/uploads/2018/11/TheARRIVE-Trial-Handout.pdf • Knight, M, 2012, ‘Amniotic fluid embolism incidence, risk factors and outcomes: a review and recommendations’, BMC Pregnancy Childbirth, 12:7 • Rydahl, E, et al, 2018, ‘Effects of induction of labor prior to post-term in low-risk pregnancies: a systematic review’. Available: https://www.ncbi.nlm.nih.gov/ pubmed/30299344 Unpacking postnatal depression – page 18 • Kendall-Tackett, K, 2007, ‘A new paradigm for depression in new mothers: the central role of inflammation and how breastfeeding and anti-inflammatory treatments protect maternal mental health’, International Breastfeeding Journal, 2(6) • Slykerman, RF et al, 2017, ‘Effect of Lactobacillus rhamnosus HN001 in Pregnancy on Postpartum Symptoms of Depression and Anxiety: A Randomised Double-blind Placebo-controlled Trial’, EBioMedicine, 24, 159-165 The problem with plastic – page 28 • Alfreds, D, ‘Here's how much plastic every South African uses – and the number is shocking’, 4 October 2018. Available: https://www.news24.com/Green/ News/heres-how-much-plastic-everysouth-african-uses-and-the-number-isshocking-20181004 • EcoNet, ‘7 Types of Plastic Wreaking Havoc on Our Health’, 23 March 2016. Available: https://www.ecowatch.com/7types-of-plastic-wreaking-havoc-on-ourhealth-1882198584.html • Gifford, D, ‘Avoiding toxins in plastic’. Available: https://www.smallfootprintfamily. com/avoiding-toxins-in-plastic • Institute for Agriculture and Trade Policy, ‘Smart Plastics Guide Healthier Food Uses of Plastics’. Available: https:// myplasticfreelife.com/wp-content/ uploads/2009/04/plastics_guide.pdf • Mercola, ‘How to Recognize the Plastics That are Hazardous to You’, 11 April 2013. Available: https://articles.mercola.com/ sites/articles/archive/2013/04/11/plasticuse.aspx • Odent, M, 2011, Childbirth in the Age of Plastics, Pinter & Martin

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PhD labour pain is worth it in the end! Sensitive Midwifery Magazine has long observed the birth pangs of, and empathised with, research midwives

hat’s why out-going editor Sister Lilian cajoled incoming editor and all-but-PhD qualified Margreet Wibbelink to share her experience, and to get the input of her supportive PhD supervisor, Professor Sindiwe James of Nelson Mandela University (NMU) in Port Elizabeth. Says an elated though exhausted Margreet: ‘I recently submitted my PhD thesis after a four-year journey. And what a journey it was! Now though, I want to encourage any PhD candidates out there to never give up! It has been one of the toughest and yet best things I have accomplished.’

Margreet and her supervisors Professors Sindiwe James and Ann Thomson

learnt to check her own attitude, which she feels is wisdom that she learnt from Professor James. ‘A healthy pressure is needed to make me perform better, and let’s be real, a PhD is a lot of hard work! It often feels like it will never end, but it will,’ encourages Margreet with the wisdom of hindsight.

And so the journey begins If it wasn’t for Professor James, Margreet says she would never have made it to PhD level. Eight years ago, she did a study to complete her Advanced Midwifery degree through NMU. Once an article was published from that research, Margreet realised that her work had a relevant contribution to make, and the researcher in her was triggered. Professor James identified her potential and encouraged Margreet to continue with a Master’s degree and then a PhD.

One step at a time

Professor James addresses the all-too-common relationship challenges between supervisors and PhD students in her well-known, insightful manner: ‘The relationship between PhD student and supervisor is vital. Even though it can be challenging at times, and students may feel that they are being stymied in their progress, the purpose of the feedback a supervisor gives is to help the candidate, not to destroy them.’

Professor James and Margreet concur that if a PhD student were to know ahead of time that the process was so long and arduous, many probably wouldn’t start at all. The message is not to shy away from doing much-needed midwifery research, but to take one step at a time. Both feel that research is like having a baby – it is with you all the time and it needs constant attention to thrive. You can’t really know the outcome and even though it is tough at times, you must decide to enjoy the journey and celebrate little victories along the way to stay motivated. Once your proposal is done and approved, celebrate that. See your first interview done as an achievement.

Margreet feels she successfully reached the end because she and Professor James cultivated an open and honest relationship; she was free to talk things out when she felt they weren’t right; and she

Try not to get overwhelmed with everything that is still waiting for you – just stay at it. You can do this, and your research is so valuable to the profession of midwifery!

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