It is now published! Available on Amazon – that was quite a journey. Made wonderful by a team of amazing chapter authors and my lovely friend and colleague Dr Jenny Hall as Co-editor. The official launch will be at the Normal labour and Birth research conference early October at Grange over Sands, UK. We hope it brings this conversation to the table or at least begin a conversation. To find oneself, in whatever capacity, in and around childbirth, is to be moved and transformed by an event in human life that is significant on so many individual and societal levels. Enjoy the read and let me know your thoughts.
Quick update. Pre orders now available on Amazon. Publishing date 19th Sept 2017
The manuscript for the book has now been submitted to the publishers. Jenny and I are hoping to get the book launched by or during the International Confederation of Midwives conference in June 2017, Toronto.
A four-day Hermeneutic Phenomenology Methodology Course (3-6th April, 2017)
The University of Central Lancashire and Robert Gordon University are delighted to invite you to attend the following:
A four-day Hermeneutic Phenomenology Methodology Course (3-6th April, 2017) aimed at postgraduate research students, researchers and academics working within health and social care areas who are new/novices in this theoretical and methodological approach. During the course, participants will receive an introduction to, and beginning experience in, designing hermeneutic phenomenology studies, collecting and analysing data, and reporting themes, qualities and patterns. (Please note this event includes a three-day methodology course and attendance at the one-day symposium detailed below)
A one-day Hermeneutic Phenomenology Symposium (6th April, 2017) aimed at postgraduate research students, researchers and academics working within health and social care. This is an exciting opportunity to listen to experienced researchers who have used a hermeneutic phenomenological approach to a) highlight some of the challenges…
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Hi all. Dr Gill Thomson and I have finalised the program for the 4th day of a hermeneutic Phenomenology methodology course (see previous blog). The 4th day is an exciting and inspiring symposium open to all. So even if you cannot join us for the week come along for the symposium. Attached is information to wet your interpretive appetites. A great line up of hermeneutic phenomenological scholars. See you there for a day of dialogue! Looking forward to a feast of thinking!
Last week I had the wonderful opportunity to be part of an interactive event in Dundee. It was the 2nd Scottish Improvement Science Collaborating Centre (SISCC). A wonderful liberating and inspiring day. I just want to share some insights that came during the day which focused on care and compassion.
I was confronted by a series of questions that arose both within myself and in communication with others:
- What is compassion?
- Where does it come from?
- Does it dwell within us or outside of us?
- Can compassion be taught and learnt?
- Is compassion an innate human quality?
- How can compassionate care be spread to places where it may not yet be realised?
My personal life experience is that compassion is a quality and energy that manifests, and awakens between us within relationship. Such relationship is born of communications both silent and spoken. It is in the richness of a reciprocal dialogue that the possibility of empathy and compassion awakens. For me it is a way of being in the world and being with others.
Following last week I am left wondering how do institutions and organisations in which we work enable and disable the potential for compassion to be revealed? Do our organisations ensure relationships can flourish? I am thinking of organisational structures that resonate at a particular tone or mood of fear and control that may not value human connection in which compassion can thrive.
What does the organisation you work for value most? I’m not speaking of written policy, guidelines and organisational rhetoric but coalface interactions between and through all layers of an organisation. Does the context you work for allow the magic between people to unfold and energise compassion? Are the the conversations we have with colleagues and users of services based on a democratic dialogue, that is to say, does our use of language create a level playing field between us?
For compassion to thrive and inform our connections with others a particular mood is required. A mood of congeniality, openness, transparency, care and tenderness. If we understand that we have to be in one mood or another and that we cannot be without a mood then the mood of a places and persons are significant. If a mood permeating your place of work is largely fear based then that is how that environment comes to be understood and how all interactions in that environment become interpreted. I would contend that in that mood a maternity (or any health environment) unfolds into a risk orientated experience. That can feel threatening and stressful.
I remember transferring a women into a hospital from community. I was happy to see an old colleague on duty in the hospital yet the communication between us was uneasy. I was confused and disoriented. I was met by a host of questions about the care I had provided prior to admission. This was all necessary yet it was the tone of the communication that left me feeling uneasy. The obstetrician then entered and the mood drifted into antagonism which translated into a barrage of risk discourse that awakened anxiety both for me and the family I was working with. I remember becoming overly judgemental of my own decision making, second guessing myself and feeling defensive. I was on guard and felt no sense of connection between the staff and myself. I went quiet.
My relationship with the mother and partner became challenging as they too were being pulled into this new mood since being admitted. Suddenly everything became dangerous and risky. We transferred in for slow progress of labour and maternal request for analgesia. It felt we had arrived just in time to stop a terrible outcome! I felt that no one was having a good day in that environment.
On the other hand I have admitted from a homebirth with a woman having a retained placenta and been met with congeniality, respect and a listening ear. The admitting midwife made me a coffee whilst I admitted the woman and spoke to the doctor. The admitting doctor was friendly and professional. The mood on both occasions was startlingly different. Although the outcomes both times were positive for mother and baby in terms of physical needs there was a tangible felt difference postnatal in my relationships with the mothers. In the first story I went home exhausted, questioning my abilities and feeling frustrated. The postnatal care did not flow easily in the way I had hoped. In the second story I felt connected to my colleagues and went home feeling part of a team and that I had done a good job. The compassion in the second story left me sustained and nourished my relationship with the mother throughout the postnatal period.
Compassion is a quality awaiting a fertile ground to awaken and grow. Once compassion and care takes root it can nurture the possibility of compassionate connections in each moment. So for me compassion requires the right ground, a freeing type of resonance. Once the mood of an organisation shifts from one that narrows potential, for example when fearful, to one that opens to possibility something enlightening between us awakens. A spark of compassion, once a spark of a potential flame awakens it can be fanned into a roaring fire warming and bringing brightness to all our encounters.
Let us think about how our leadership is attuned? Our colleagues? Our policy makers? Our researches? Our educators? Our new graduates?
Maternity and midwifery have been shown repeatedly to be based on relationships. Indeed it is the relationships that keep care safe. Midwives are the ambassadors of maternity care and have a responsibility to safeguard what is precious in childbirth and ensure its continuance is holistically orientated. Facilitating and turning to moods that enable compassion to flourish between us is therefore worthy of our efforts. We may or may not have innate compassion, in a certain sense that does not matter. However we can be accountable to the moods which we contribute to and choose to awaken and we can also decide the moods we choose to turn away from. We just need to be aware of moods and take notice of the affects certain moods have on ourselves and others.
For me the good news is that compassion awaits us all. It is not dependent on whether you or your colleague next to you has a good amount of innate compassion! The notion of compassion being inside or outside creates a kind of false objective -subjective dichotomy that is antithetical to compassion. Compassion wants to gift us all those wonderful experiences that come from giving and yielding to each other. Compassion is thus realised and expressed in our relational encounters. Compassion for me is thus unfolding moments between us in the reciprocal play of our interactions. Without the play between us compassion finds no ground to take root and grow. Compassion only asks for a fertile ground to grow and come forth. The delight of feeling compassion once awakened between us reminds us of our shared human needs of wanting to be understood to feel loved and to feel safe.
It may only take a kindly moment of eye contact, perhaps a smile and some gentle verbal acknowledgement of the others you meet and work with. Such moments can be the fan that ignites the flame of compassion between us.
The book will draw attention to the beginning of life; a poignant human journey that holds meaning and significance within and beyond current maternity care systems.
Hi all. I have received a variety of comments and feedback about caseload, continuity of carer midwifery practice. Would love to hear more. So vital to share our examples. There is a lot of misconceptions and fears about this way of providing midwifery. Also if you received care from a caseload midwife and want to contribute you are welcome! Let us have a conversation. My example was previous blog…..
Kind regards, go well
Focus on safety safety safety breeds fear,
fear then attunes us to more fear and then
the situations we find ourselves in, like childbirth,
become coloured by more fearful feelings ….
then it all feels even less safe!
Being constantly fearful is an unsafe place to dwell, function and be human,
we are simply not free when we are fearful!
Needing to feel safe is a human need yet it need not imprison us
let us not cover over what it means to be human in the pursuit of safety;
find ways of being and doing that awaken our potential to
flourish and feel safe and free
Susan Crowther 2016
There has been a lot of conversations across social media and various fora about caseload midwifery and working towards a continuity of carer model. There is a lot of anxiety and myth, misperceptions and unfounded concerns. I have had the pleasure to work across various systems in the UK and overseas. In the UK I worked in a group practice, standard maternity care and as an independent midwife. The standard fragmented care in which primary and secondary services are separately staffed simply did not resonate with me. The group practice arrangements I worked in at Chelsea and Westminster hospital in the 90s, although fun at the start, also were frustrating and exhausted me. Working independently in the UK was wonderful yet very stressful at times due to not being fully integrated into the system and the need to ask for payment. When I worked in New Zealand it was a fully integrated system in which women booked a midwife directly without having to pay when they were a resident or citizen. I have described the NZ system elsewhere.
I am not going to re-state the supporting research evidence for caseloading, you can find that elsewhere. What I want to do here is first describe what continuity of carer is for me. It is being the main point of contact for a women through pregnancy, labour and birth then postnatal. Care is only handed to others when I am on holiday, weekends off, sick, study days or have two women go into labour at the same time! The care I provide traverses risk and chosen location for birth. I follow the women where she intends to birth. The arrangement is flexible and agreed in partnership at each step of the journey.
For caseloading to work I needed:
- Excellent support structure with colleagues
- Like minded colleagues who were philosophically aligned
- Fair remuneration for the work I did that was equitable and matched the level of skill. Payment to be organised through ministry of health and be free at point of delivery to women.
- Regular time off arranged with practice partner.
- Self determine my ways of working, e.g. When to do clinics, postnatal visits, Case load numbers, organising annual leave and weekends off call in liaison with practice partner.
- One full month off for AL per year in one go, plus another week decided amongst group practice.
- Partnership working with women that was reciprocally sensitive to each other’s needs
- Time to be off call when needed urgently.
- Generosity of spirt and good communications amongst colleagues
- Excellent relationships at interface with hospital colleagues (midwives and medical)
- Regular support and guidance from the midwifery council and college of midwives
- Understanding family who supported my way of working
- Great rapport with everyone in my local community where I was working
- Reliable car and phone!
Caseload 4-6 per month. Reasonable living wage that was slightly more than colleagues working shift work in the hospital. The payment for caseload midwives in NZ is presently being challenged to meet inflation and degree of responsibility. At the time of this diary entry the 4-6/month booked women provided an adequate pay yet this had not increased with inflation hence current challenge.
I worked with 8 other caseload midwives split into partnerships for weekend off call, holidays, SDs, sick, 2nd midwife for primary births and when need support for long labours or when two women go into labour at the same time! Clinic times and postnatal visit times decided by myself and confirmed with women as needed. Key is flexibility. Some midwives prefer to do all clinics in one day, all bookings another day for example. Partnership is essential between the women and myself as well as with practice partner, group practice and associated support services such as GPs, primary birth unit staff and local hospital colleagues.
So what did a month look like? Was I over worked? Was being on call a constant intrusion in my life? Did women abuse the on call system and call me constantly?
Here is one month activity from my practice diary. All names and places have been removed. Each month was different but this gives you a snap shot.
So here it is…
Monday. On call, Antenatal clinic 8-12noon (8 women). Postnatal visits x3 X1 booking (2 hours). Home by 430pm. No calls
Tuesday on call x4 Post natal visits in morning. Office admin work afternoon. No calls.
Wednesday on call 3 post natal visits in morning. Afternoon free. No calls.
Thursday on call antenatal clinic (8 women). X2 PN visits. Practice meeting cancelled everyone busy. Home at 3pm. Called at 10pm to a birth. Home at 8am Friday morning.
Friday on call. Morning free to sleep. X4 postnatal visits in afternoon. Home by 5pm. Practice partner took my on call 6-11pm so I could go out of area to an event.
Saturday, on call, no calls. X1 PN visit.
Sunday, on call, no calls. X1 PN visit.
(Total hours actually away from home and working = approx 36 hours)
Called out outside of Monday to Friday working days – once
Monday on call. Antenatal clinic 8-12. PN visits x4. Home 4pm
Tuesday on call. X1 booking 9-11am. X3 postnatal visits. Home 2pm. No calls
Wednesday on call. No calls, no visits. Admin catch up (2 hours)
Thursday on call. Antenatal clinic 8-12. Practice meeting over lunch. X 4 PN visits. Home by 4pm. Took practice partners on call so she could have an evening off.
Friday called to birth at 7am. Home at 1pm. Booking 3-5pm. Called to be 2nd midwife at birth 7-11pm.
Saturday on call for my own case load and practice partner for her weekend off. X1 PN visit no calls
Sunday x2 PN visits. Free by lunchtime. Called at 5pm for BF problem.
(Total hours approx 35 hours away from home + 1-2 hours phone and admin work)
Called out or working outside working Monday to Friday working hours – twice
Monday on call. Antenatal clinic 8-12. PN visits x4. X1 booking. Home at 5pm.
Tuesday on call PN visits x2. Free from 11am. No calls
Wednesday. Called to induction of labour at 11am (post dates). Home at 11.30pm.
Thursday on call Antenatal clinic 8-11am. X 3 PN visits. Practice meeting over lunch. Home by 3pm. No calls.
Friday on call PN visits x4. Booking 1-3. Hand over on call to practice partner at 6pm.
Saturday and Sunday off call.
(Total hours approx away from home 38 + 1-2 hours phone and admin work)
Called out or working outside working Monday to Friday working hours – once
Monday on call from 8am. Antenatal clinic 8-12. PN visits x4. Called to birth at 4pm, home at 9pm.
Tuesday. Called to be birth support for practice partner at home birth 7-11am. X3 PN visits. Booking visit 3-5pm. No calls.
Wednesday. No calls all day. Did 2 hours of admin.
Thursday Antenatal clinic 8-12. Practice meeting over lunch 12-2pm. Then X2 PN visits.
Friday x3 PN. Visits. X1 booking. Perinatal mortality meeting at local hospital 1-3pm
On call from 6pm for practice partner also for weekend.
Saturday called to birth at 6am (practice partners caseload). Home by 4pm.
Sunday X1 PN visit. No other calls.
(Total hours approx working away from home 35 hours + 1-2 hours phone and admin work)
Called out outside working Monday to Friday working hours – twice
I for one flourished and loved this way of working. The rewards that I derived from the relational model of care continue to resonate throughout my perspectives on midwifery. The relationships energised and inspired me. Yes at times I was tired and wanted to ‘just turn off my phone’ yet these times were frequently ‘healed’ by the next encounter, the next birth, the next moment of awe; that as midwives we have the privilege to be invited to.
Don’t let caseloading and continuity of carer worry you or cause anxiety. It has been a wonderful part of my work as a midwife which I often miss now embedded in academia. The joys of working that way always outstripped the moments of vulnerability. Providing advice and care to women and seeing and hearing first hand how it worked or did not work so well for them shapes practice decision making. Meeting up with women again and again over the years whilst they make their families is a joy.
I would say it was being a caseloading midwife that really highlighted the art and magic of midwifery in ways that will always be dear to my heart. Don’t be afraid of caseloading, it’s sustainable, enjoyable and doable with the right support and flexibility. I know colleagues who are still flourishing after 20 years working this way, colleagues with young children, colleagues who just qualified and colleagues who had never worked in the community prior to caseloading. The barriers to this way of working can be overcome with the support, desire and inspiration to succeed.
What do others think? Would this work in the Uk? Would this work as a national approach for Scotland for example? Do you have your own experiences?
In this blog I want to share my transition to working as a practising midwife in a totally different system from the NHS and independent midwifery roles in the UK. I had worked extensively both in the NHS and independently as a midwife. My passion is and always will be family centred primary focussed continuity of care. I love it, thrive on it, inspired and energised by that model of care. Long before all the evidence started stacking up in favour of continuity and primary birthing I was hooked, convinced and intuitively just knew it is how I must work.
After working at Queen Charlottes Hospital in West London with its massive rates of epidurals, feeling downtrodden by a system that continually frustrated me, I moved to a group practice with the newly established Chelsea & Westminster maternity services under the management of Paul Lewis in the mid 90s. The seminal moment at QCH came when I chose to follow a mother from the antenatal induction of labour area to the labour ward. She was scared and had come to trust me throughout my shift. I went upstairs and provided continuity until after her birth. I was reprimanded for leaving the AN ward despite getting a colleague to take my place for the shift. Going into a group practice at Chelsea and Westminsiter was super exciting. Changing childbirth was a real possibility for change. Yet I still craved the continuity 1:1 relationship. So I went independent in and
around London and Surrey. Loved it but didn’t like having to ask for payment. I then worked as a midwife in France (long story for another blog!). Returning to the UK I continued in a community Group Practice in south London before going to Cambridge to be the first consultant midwife at Addenbrookes. That was a whole adventure (I’ll save that for another blog!)
Then to NZ. In midwifery terms I had died and gone to heaven! I spent a short time locuming in a Auckland hospital. Then swiftly moved rurally and within weeks was booking women for full childbirth care. No need to speak about money, no need to speak about insurance, (New Zealand has a no fault compensation system called ACC), no need to speak about who is in charge of my days on or days off! I was self-employed booking as many women as I wanted and being paid for the midwifery work I did.
In NZ women ask around, look in papers, yellow pages, look on notice boards and ring around to find the midwife they want to work with. They can even find a midwife online:
For my part I advertised and got known. I was in the local press, interviewed on a local rural radio station and attended several women’s support groups in the area. In one month I was busy. One month I was dashing to three births in one night! That was very unusual. Most months I had 4-6 births due. After the first year word of mouth is the most powerful way to gain more mothers for care.
Once a woman has decided to book with me we both sign a contract. This contracts me to provide full midwifery services. This then gets sent to the Ministry of health (DoH in the UK). The ministry then pays me. Such a great system. In New Zealand about 50% of midwives work as self employed caseload midwives 50% as employed working mainly in facilities. All midwives from qualifying and being certified to practice choose which area she practices. Some midwives spend time in both areas in the course of their careers.
I was living pretty rurally at the time so needed to ensure I had back up and good networks. This is vital in rural caseload midwifery. I got to know everyone as you can imagine. Sometimes I could be super busy others more calm. But what is always beautiful is the depth of connection forged with women and their families from 1st trimester booking to 6 week postnatal discharge. The collaboration, working together and guardianship of that precious time is warming and ackowledging of the human capacity to be together in health care. I felt the childbirth process unfolded more safely due to that relationship, knowing women over time allowed for red flags to become easily visible.
Knowing women allows for the felt experience to be magnified. The spirit of childbirth over the extended rapport with women and families comes alive. I have been at births when 4 generations are present…magic. I am so often moved to tears and feel the hairs on the back of my neck stand up on end in the sheer joy of those Kairos moments. Yes I am tired at times but knowing woman when they call me in labour is far less exhausting and stressful than shift work and fragmented care. Being woken up at 3am to attend a birth of someone you know well is so different to waking for an early shift at the hospital.
As a Lead Maternity Carer (LMC as named in NZ) midwife I am able to get full access agreements with local hospitals to ensure continuity is safeguarded. At these times I honour and respect my hospital based core midwifery colleagues. With them higher risk women get the midwifery expertise required in addition to the primary focus I provide as the LMC. The interface of primary and secondary service misunderstandings and differences fades. Women are in the centre of care.
NZ midwifery is a truly integrated service. I said to a group of student midwives in the UK before I came to NZ how working in 1:1 ways with women over the childbearing year brings the felt experience of being a midwife to a whole different level. I now work with student midwives who have this embedded as the infrastructure of NZ maternity models of midwifery. Partnership, collaboration, protection and continuity lie at the centre of the philosophy of midwifery in NZ.
Watching a women grow into her breastfeeding confidence over 6 weeks knowing you have provided consistent advice from AN, immediate postnatal when she first meets her baby and then ongoing support…pure magic. To work with a woman who is terrified of labour and birth and to watch her roar with delight as her baby emerges in water at home and see the power and rawness of a new being unfold infront of me, to have the elder children that I helped into the world watch on as I return to the family each year to see a new sibling come join the party, magic. Yes sometimes things do not go to plan. But with well formed relationships so many things are possible, even when outcomes are not positive. The relationship helps, heals and restores.
I was invited to the funeral of a neonatal death due to fetal abnormalities. It was a traditional ceremony in a Maori Marae (meeting house), I was invited to speak and sing for the baby. The whole ceremony was nourishing and healing. The eye to eye contact, the hugs the authentic being together in human pain was healing and freeing. Relationships and partnership are key to midwifery; birth is always significant whatever the outcomes requiring tact and sensitivity – connectedness.
Continuity of care is evidenced based, many midwives experience working this way, we are learning how continuity is sustainable, how continuity can be the very aspect of midwifery that maintains passion and joy of practice. It is not a gold standard, it is a minimum standard for all mothers, regardless of risk, place of birth. Yet we all all need to ensure that a philosophy of childbirth and midwifery is deeply grounded in trust and appreciation of physiology, a way of attuning that honours the invisible qualities of childbirth, the spirit, heart and hold what is most sacred. Only then does continuity truly rise above the technocracy and fear surrounding childbirth. Fear can be moved to joy allowing all possibilities to arise!
Do you want to work in New Zealand? Working in NZ requires adjustment and further study. NZ midwives on qualifying are able to prescribe for childbirth related things (UTIs, mastitis, thrush for example). NZ midwives on qualifying need to be proficient in neonatal examinations and be confident providing care from early 1st trimester including miscarriage care, intepret scans, blood results and make referrals. I remember being professionally challenged ordering serial blood tests to measure HCG levels for a mother with threatened miscarriage shortly after arriving in NZ. With help from practice partners I learnt what I needed to do and say to provide support to this mother. Post natal care extends to 6 weeks; after my UK postnatal 28 days experience there was much to learn here also! The learning curve at the start can be steep and also includes gaining appreciation of a bi-cultural society and the history of colonisation on indigenous Maori. Transitioning from UK midwifery to New Zealand midwifery can be challenging yet that challenge depends on what you have done previously, what you want to do and how adaptable and open you are.
That is a taster of my own felt experience. Hope it adds to your thinking about the myriad potentials in midwifery.
Here is some useful links to explore more….
This is another reminder about how brutish the moment of birth can be. How those there when a new person arrives can turn from the wonder of Kairos at birth. Thank you for this blog that I share again here
Picture this… A mother sits holding her newborn son on a postnatal ward during visiting time. One of her visitors reaches forward, grasps the baby by the head and pulls him out of his mothers arms leaving him dangling by his neck. Can you imagine the reaction of the mother and those around? Yet no one raises an eyebrow when this occurs during birth.
If we accept that human babies are people and have feelings (both physical and emotional) why do we accept how many babies are treated during birth? What is the experience of birth like from the perspective of the baby? I realise that the following are extreme examples, but this approach is common place worldwide.
A medical approach to welcoming a baby to the world
Once the baby has been ‘removed’ their first minutes are spent away from their mother being subjected…
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This is a short blog to garner a dialogue I hope. I am curious about how midwives feel the need to feel in someway “other” to colleagues in the maternity team. I have been guilty at times of feeling the need to safeguard the sanctity of midwifery from others that I perceive don’t understand. Or feel a need to protect and shelter what is precious in midwifery from those I believe will overpower my own professional position, stand, opinion and indeterminate knowing that directs my art of practice.
Yet is such positioning helpful, constructive and empowering? I am proud to stand as a midwife within my community. I live and work in a community of practice with lay as well as registered medical colleagues. I know my skill set, my scope of practice and have a knowing that stirs within me and bubbles up into action when needed. Such intuitive knowing is a wellspring of knowledge issuing forth just beyond my visual awareness; an historical and cultural embodied knowing. A knowing that brings deep awareness of how I stand on the shoulders of giants. Of a vast history. I need not be intimidated and lash out, avoid, do good by stealth, aggressively reject what I disagree with or even passionately accept what fits my present knowing – others may feel awkward in hearing my over zealous self righteousness. They perhaps have a different knowing. They may feel attacked, unacknowledged and grow uneasy around me. These encounters of difference, of divergent ideas are merely an opportunity to explore more of the complexity that is childbirth.
The knowledge and embodied knowing about birth does not belong to an individual group, time, place or person.
It is not feasible that anyone person or professional Group can hold all there is to know. Surely no one would claim this?
What matters most to us all is – being safe, feeling safe, being loved, being seen, being with-others respectfully. What matters is that we all engage in miracles daily. We, those privileged to be at birth, get to be at the time of an exquisite specialness. A time which is the greatest of equalises. A time when we can gather in awe at the mysteriousness of life! Surely that transcends any professional differences and conflict; surely within this living kairos time the silent voices of our collective inner selves are permitted to sing out in unison? We can transcend, just for a moment, the divergent discourses that serve us little when what matters most arrives as a message in a bottle from beyond the horizon. This is a celebration of our diversity and differing ways of coming to our knowing. Then we see there is nothing to protect. Then we become still and silenced.
What do you feel?
“Rachel was born at home, unplanned. In the lounge of course, right in the middle of winter. She came on hard and fast. I just woke up about 9.30 with feeling uncomfortable again nothing really, just niggles. Went back to bed I rang Sam [midwife] at about 10.30, said “I’ve had a couple of contractions, nothing regular”. She said “Do you want me to come around”. We’d just had a snowfall that weekend the roads were quite dodgy so needed to make the decision to travel or not. It can take a good hour and a half, two hours to the rural unit depending on conditions and up to 4 hours to the hospital. So it was a bit scarier especially at night time. The gorge passes can be quite treacherous with ice and snow on the roads. I cracked on – the road trip was not happening, they’d all decided for me but the decision had to be mine. I wasn’t frightening at all. It was horrible outside, cold and the roads were really bad. I had visions of getting stuck on top of the gorge and having the baby out side with my bare bum out in the middle of the snow. I was not leaving even if others wanted me to, not with that length of time travelling and the terrible weather conditions. I was comfortable here at home, it was really lovely. The fire was roaring, put the jug on, and had a cup of tea. Sam called her second midwife and popped home and got her home birth bag. We had a cup of tea and settled in basically, parked up, and let things progress – just did what I needed to do”
Things are certainly not as straight forward as we would often believe them to be as Lynn’s story narrates. I am now dwelling amongst pages upon pages of post doc gathered data. The data is brimming with stories of maternity care lived experienced descriptions from a wonderful host of participants as the one above. I am always bemused and delighted when I come to the part of qualitative research that involves ‘letting arrive what needs to arrive’ from the data. Amidst the seemingly overwhelming complexity of life rendered in these gifted stories are the shared meanings that gesture towards our together humanness! In this is the possibility of transformative understandings and how to go forward. At the end of day I’m a swirling energy of interpretive images and words punctuated by my exclamations of “yes”, “perhaps”, “oh I feel that”,” I see what that means”, “where is my note pad and pen” “oh wait there is more”. No-one warns one of the insomnia that can plague a qualitative researcher once immersed in stories about life.
To be fully engrossed in the process is to be witness to the Dionysian possibility of ceaseless convergence and divergence. It is to find oneself in Kairos time when fixed notions of the “final answers, solutions and conclusions” find no resting place. There never seems a ‘right’ time to stop for the day – nor is there a moment when interpretation is complete! I find it liberating and freeing not to have it wrapped up and formulaic. To be released from the need to have the final word on any phenomenon is absurd yet funded research demands the ‘output’.
Apollo directs into reason, systems and defined predictable processes
The often spoken secret between us Hermeneutic phenomenologists is knowing there never will be one definitive conclusion; there will always be ‘on-the-way’ findings ‘that satisfies’ the funding agency and those that accept your work for publication. I say secret because however many times I say that this type of ontological work bellies any finality I’m repeatedly asked “so what was your final conclusion?” – I smile, “There simply is no ending to the process of life”.
Maternity care provision in the remote regions of New Zealand is a tale of paradoxical tensions. This tension is between the need to let go into the uncharted yet inspiring territory of what may lay beyond the imagination of our own experiences while taking heed to the Apollonian structured world of the modern maternity systems when ‘things’ are made controllable, timed, charted, documented, where protocols and guidelines dominate and attempt to construct and hold that world together. There is the nearness of being home and feeling safe and fear when one is far from the highly structured world of medical help when needed.
Rural living tells a story of being on the edge and outside of that controlled environment of the 21st century maternity hospital. I see and ‘feel’ hard working down-to-earth pioneer types living frontier lives in these remote regions. People dealing with the challenges of isolation and close community; of scenic places that are often holiday destinations for many of us yet are the homes and birth places of many.
I will not speak in this blog entry further on the findings for that will come later, I promise! For now I am intrigued about the paradox as stated above.
This research, like maternity care in rural areas and birth itself requires an openness, receptivity and trust. These unfolding emergent processes epitomize the Dionysian approach. As researcher and midwife I find myself being reminded on this journey that responding to what emerges is about attuning with wonder to what surfaces in a kind of creative evolutionary flow. To be immersed in research that seeks to reveal meaning is to drink of the intoxicating Dionysian wine that releases me to go beyond constraints; it can make me dizzy! In my research on Joy at Birth I wrote:
The birth experience uncovers a drawing near of divinity that puts us face to face with Otto’s holy-other as Dionysus the ecstatic liberator from worldly concerns “… something that captivates and transports … with a strange ravishment, rising often enough to the pitch of dizzy intoxication…” (Otto, 1917/1923, p. 31). I am reminded of the lovely madness just after many births when everyone is intoxicated, fascinated and enchanted. Something enchanting is experienced that can be a moment of transformation; a moment in which we find ourselves able to go forward into new understandings.
I then wrote in my field notes at the time:
As soon as baby came the father held his son up to the night sky offering an Islamic prayer, all the hairs on the back of my neck stood up. This was a holy moment, I continued to attend to the mother yet there was such a presence that touched and thrilled me to tears. [Field notes 2011].
The mood of the Apollonian thinking that comprises systems, measures and to do lists would appear at odds with this intoxicating freedom. Yet that is not what I argue. Both the Apollonian and Dionysian ways of attuning speak to us as humans. Actions in the remote regions to secure safety and positive outcomes require planned actions, sharpened clinical decision making and critical thinking.
A recent heated discussion on social media concerning midwives and promotion of normal birth provoked condemnation from some quarters. Again the splitting of ways in the normal vs abnormal debate bears no useful long term fruit. What is important is acknowledging and appreciating that we are always somehow in the dance of the Dionysian and Apollonian paradox. Statistics at times can be used as weapons to prove “being right” and held up to be the sole voice of reason. Conversely an emotional charged flow of words can imply “rightness” – yet this ‘feeling’ contribution to the debate can be accused of being chaotic, unreasoned and therefore less valued. Both however can come at us like arrows of righteousness and strike us wherever we are situated.
As Rumi, a sufi mystic poet said in the 13th Century:
“Out beyond ideas of wrongdoing and rightdoing, there is a field. I’ll meet you there”
To dichotomise appears to be the domain of inflexible thinking that seeks rightness and disregard of the other. Likewise I am finding once again that the research project (whatever it may be) requires a Dionysian openness and flexibility. At the same time I need to pay attention to the more Apollonian disciplined processes such as the ethics procedures, funding applications, attention to literature (yes -quantitative and qualitative) and the academic restraint on styles of writing. It is in a sense a dance in Rumi’s field. It is neither this nor that, not a wrong way or a right way it is always dialectic, constantly both, one within the other…that is the tension.
Lynn had planned on a facility birth yet had her baby at home by the warmth of her own fire after a cup of tea with her husband and the local rural midwives. The snow storm and the worrisome distance from hospitals and secondary services lie beyond this tender scene. The story reveals qualities of relationships, trust, surrender and feeling safe. Life is always far more than we can predict and order.
For me it is about letting go of being right OR wrong and enjoying the fun of being finite in a universe of infinite possibilities that confound us! Befriend your Dionysian and Apollonian qualities.