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Caseload – verloskunde is duurzame verloskunde: een persoonlijk relaas

A blog a wrote in May 2016 about my personal experience in sustainable caseloading in midwifery has been translated by a colleague, Tine Oudshoorn, into Dutch.

Er is veel gesproken op sociale media en diverse internationale fora over caseload – verloskunde en werken met persoonlijke continuïteit van zorg (gehele proces) die het model nastreeft. Er bestaat nogal wat opwinding over; veel mythes, misvattingen en ongegronde bezorgdheid gaan rond. Ik had het genoegen in verschillende geboortezorg systemen te werken in het Verenigd Koninkrijk en erbuiten. In het Verenigd Koninkrijk werkte ik in een groepspraktijk met standaard verloskundige zorg en als zelfstandige verloskundige. De standaard verloskundige zorg, waarbij de 1e- en 2e-lijnszorg gescheiden zijn appelleerde eenvoudigweg niet aan mijn behoeften.

De groepspraktijk regelingen in de praktijk van het Chelsea en Westminster ziekenhuis, waar ik werkte in de jaren ’90, hoewel leuk in het begin, waren ook frustrerend en putte mij uit. Zelfstandig werken in het Verenigd Koninkrijk was geweldig, maar wel erg stressvol, doordat het niet volledig geïntegreerd is in het zorgsysteem en de noodzaak bestaat om betaling te vragen voor je diensten.

In Nieuw-Zeeland waar ik werkte, is de vrijgevestigde verloskundige volledig geïntegreerd in het zorgsysteem, waarbij vrouwen een verloskundige rechtstreeks boeken, zonder betaling als ingezetene of burger van Nieuw-Zeeland. Ik heb het Nieuw-Zeelandse verloskunde systeem al eerder elders beschreven.

Ik ga hier niet opnieuw de onderbouwing van caseload – verloskunde opsommen, die vindt je elders. Wat ik hier eerst ga beschrijven is wat persoonlijke continuïteit van zorg voor mij is. Het is ‘het meest’ ter zake doende en meest belangrijke in de contacten tussen de vrouw en de verloskundige tijdens de zwangerschap, de bevalling en het kraambed. Zorg wordt alleen overgedragen aan anderen, als ik op vakantie ben, een weekend vrij heb, bij ziekte of studiedagen en als er twee vrouwen tegelijk gaan bevallen! De zorg die ik verstrek doorkruist risico’s en de gekozen plaats bevalling. Ik volg vrouwen naar de haar geprefereerde plaats bevalling. De regeling is flexibel. Er wordt doorlopend op gelijkwaardige wijze (in partnership) tussen vrouw en verloskundige overeengekomen wat de volgende stap is.

Om te werken als caseload – verloskundige had ik nodig:
• Een uitstekende ondersteunende structuur (netwerk) met collega ‘s.
• Gelijkgestemde collega’s die qua filosofie en visie op dezelfde lijn zitten.
• Eerlijke vergoeding voor het werk dat ik deed, afgestemd op- en overeenkomend met het niveau van mijn vaardigheid. De betaling georganiseerd door het ministerie van volksgezondheid en gratis voor vrouwen.
• Regelmatige verlofregeling in overleg met een vaste praktijkpartner.
• Zelfregelend en autonoom werken, zoals het zelf bepalen wanneer prenatale zorg en postnatale zorg gedaan worden. Zelf het aantal volledige begeleidingen per jaar bepalen en de jaarlijkse rustperiode en vrije weekenden in overleg met de vaste praktijkpartner regelen.
• Eén volledige maand onafgebroken vrijaf zijn per jaar, plus een week vrijaf in overleg met de vaste praktijkpartner.
• Werken in partnerschip met vrouwen, dat wederkerig sensitief was en tegemoet kwam aan beider behoeften.
• Gelegenheid en tijd om ‘geen dienst te hebben’ als dat dringend nodig is.
• Genereuze open sfeer en goede communicatie tussen collega’s.
• Uitstekende werkrelaties met ziekenhuiscollega’s (verloskundigen en artsen).
• Regelmatige ondersteuning en begeleiding van de Midwifery Councel en College of Midwives (organisatie van verloskundigen).
• Begripvolle familie die ondersteunend is aan mijn manier van werken.
• Goede verstandhouding met iedereen (de gemeenschap) in de vestigingsplaats waar ik werkte.
• Betrouwbare auto en telefoon!

Achtergrond
De caseload was 4 – 6 bevallingen per maand. Dat genereerde redelijke inkomsten, iets meer dan collega’s die in ploegendiensten in het ziekenhuis werken. De betaling van caseload – verloskundigen in Nieuw Zeeland zet momenteel aan tot nadenken. Aanpassing is nodig om te voldoen aan inflatie en de mate van de verantwoordelijkheid. Op het moment dat ik dit schrijf staan 4 – 6 bevallingen per maand voor een adequate beloning, maar dit is nog niet verhoogd met de inflatie en daarmee een actuele uitdaging.
Ik werkte samen met 8 andere caseload – verloskundigen, opgesplitst in partnerschips van twee collega’s die elkaars partner zijn en waarnemer bij vrije weekends, vakantie- en studiedagen of ziekte. De tweede verloskundige is ook beschikbaar voor primi para bevallingen, of hulp bij langdurige bevallingen of als twee vrouwen tegelijk gaan bevallen! Spreekuur tijden, huisbezoeken en kraamvisites bepaal ikzelf in overleg met de vrouwen. Ik verzet afspraken in overleg met de vrouwen als dat nodig is. Flexibiliteit is de sleutel.

Sommige caseload – verloskundigen prefereren het om alle prenatale zorg op één bepaalde dag te plannen en bij voorbeeld nieuwe aanmeldingen, kennismaking en volledige intake, op een andere dag te doen.

Partnerschap is van essentieel belang tussen de vrouwen en mezelf, mijn praktijkpartner/waarneemster, de groepspraktijk waar we deel van uitmaken en de bijbehorende ondersteunende diensten, zoals de huisartsen, de geboortehuis staf en de plaatselijke ziekenhuiscollega’s.

Hoe ziet een maand werken als caseload – verloskundige eruit? Was ik overwerkt na die maand? Was de doorlopende aanwezigheidsdienst een constante verstoring van- of druk op mijn privé leven? Maakten vrouwen misbruik van mijn constante aanwezigheid en belden ze mij voortdurend?
Hieronder één maand van activiteiten uit het dagboek van mijn praktijk. Alle namen en plaatsen zijn verwijderd. Iedere maand was anders, maar dit voorbeeld geeft je een momentopname.

Daar gaan we …

Week één

• Maandag, dienst. Prenatale zorg in de praktijk 8.00 – 12.00 uur (8 dames). Drie kraamvisites en 1 nieuwe aanmelding, kennismaking en intake aan huis van de vrouw (2 uur). Thuis om 16.30 uur. Geen telefoontjes of oproepen.

• Dinsdag, dienst. Vier kraamvisites in de ochtend. Praktijk administratie bijgewerkt in de middag. Geen telefoontjes of oproepen.

• Woensdag, dienst. Drie kraamvisites in de ochtend. ‘S middags vrij. Geen telefoontjes of oproepen.

• Donderdag, dienst. Prenatale zorg in de praktijk (8 vrouwen). Twee kraamvisites. Praktijk vergadering geannuleerd omdat iedereen bezig was. Om 15.00 uur thuis en om 22.00 uur gebeld voor een bevalling. De volgende ochtend (vrijdag) om 08.00 uur thuisgekomen.

• Vrijdag, dienst. Ochtend vrij om te slapen. In de middag 4 kraamvisites. Thuis om 17.00 uur. Mijn praktijkpartner neemt de dienst over van 18.00 – 23.00 uur, zodat ik buiten mijn werkgebied naar een afspraak kan.

• Zaterdag, dienst. Eén kraamvisite. Geen telefoon of oproepen.

• Zondag, dienst. Eén kraamvisite. Geen telefoon of oproepen.

Totaal aantal uren weg van huis en aan het werk = ca 36 uur.

Buiten de werkdagen, maandag tot vrijdag, – één maal gebeld.

Week twee

• Maandag, dienst. Prenatale zorg in de praktijk 08.00 -12.00 uur. Vier kraamvisites. Thuis om 16.00 uur.

• Dinsdag, dienst. Nieuwe aanmelding, kennismaking en intake 09.00 – 11.00 uur. Drie kraamvisites. Thuis om 14.00 uur. Geen telefoontjes of oproepen.

• Woensdag, dienst. Geen telefoontjes of oproepen. Geen pre- of postnatale zorg. Administratie bijwerken (2 uur).

• Donderdag, dienst. Prenatale zorg in de praktijk 08.00 -12.00 uur. Praktijk vergadering tijdens de lunch. Vier kraamvisites. Thuis om 16.00 uur. Neem waar voor mijn praktijkpartner, zodat zij een avond vrij is.

• Vrijdag geroepen voor een bevalling om 07.00 uur. Thuis om 13.00 uur. Nieuwe aanmelding, kennismaking en intake 15.00 – 17.00 uur. Gebeld om als 2e verloskundige bij een bevalling aanwezig te zijn 19.00 – 23.00 uur.

• Zaterdag, dienst voor mijzelf en mijn praktijkpartner. Haar vrije weekend. Geen telefoontjes of oproepen. Eén kraamvisite.

• Zondag, dienst. Twee kraamvisites. Klaar tegen lunchtijd. Gebeld om 17 uur voor een borstvoeding probleem.

Totaal aantal uren weg van huis en aan het werk = ca 35 uur met 1 – 2 uur telefonische contacten en de administratie bijwerken.
Buiten de werkdagen, maandag tot vrijdag, – tweemaal gebeld.

Week drie

• Maandag, dienst. Prenatale zorg in de praktijk 08.00 -12.00 uur. Vier kraamvisites en één nieuwe aanmelding, kennismaking en intake. Thuis op 17.00 uur.

• Dinsdag, dienst. Twee kraamvisites. Niets te doen vanaf 11.00 uur. Geen telefoontjes of oproepen.

• Woensdag, dienst. Gebeld om een inleiding te begeleiden (over tijd) om 11.00 uur. Thuis om 23.30 uur.

• Donderdag, dienst. Prenatale zorg in de praktijk 08.00 -11.00 uur. Drie kraamvisites. Praktijk vergadering tijdens de lunch. Thuis om 15.00 uur. Geen telefoontjes of oproepen.

• Vrijdag, dienst. Vier kraamvisites. Nieuwe aanmelding, kennismaking en intake 13.00 – 15.00 uur. Overdracht aan praktijkpartner om 18.00 uur. Vrij weekend.

• Zaterdag en zondag, geen dienst.

Totaal aantal uren weg van huis en aan het werk = ca 38 uur met 1- 2 uur telefonische contacten en de administratie bijwerken.
Buiten de werkdagen, maandag tot vrijdag, – eenmaal gebeld.

Week vier

• Maandag vanaf 08.00 uur dienst. Prenatale zorg in de praktijk 08.00 -12.00 uur. Vier kraamvisites. Gebeld voor bevalling om 16.00 uur. Thuis om 21.00 uur.

• Dinsdag, dienst. Gebeld voor ondersteuning van praktijkpartner bij een thuisbevalling, van 07.00 – 11.00 uur. Drie kraamvisites. Nieuwe aanmelding, kennismaking en intake 15.00- 17.00 uur. Geen andere telefoontjes of oproepen.

• Woensdag, dienst. Geen werkzaamheden of gesprekken. De administratie in 2 uur bijgewerkt. Geen enkel telefoontje of oproep.

• Donderdag, dienst. Prenatale zorg in de praktijk 08.00 -12.00 uur. Praktijk vergadering tijdens de lunch 12.00 – 14.00 uur. Daarna twee kraamvisites.

• Vrijdag, dienst. Drie kraamvisites. Nieuwe aanmelding, kennismaling en intake (2 uur). Perinatale sterfte vergadering in plaatselijk ziekenhuis 13.00 – 15.00 uur.

Dienst vanaf 18 uur voor praktijkpartner, haar vrije weekend.

• Zaterdag, dienst. Om 6.00 uur gebeld voor assistentie van een collega (lid van de groepspraktijk die we samen voeren). Thuis om 16.00 uur.

• Zondag, dienst. Eén kraamvisite. Geen andere telefoontjes of oproepen.

Totaal aantal uren weg van huis en aan het werk = ca 35 uur met 1 – 2 uur telefonische contacten en de administratie bijwerken.

Buiten de werkdagen, maandag tot vrijdag, – tweemaal gebeld.

Ik hield ervan en floreerde met deze manier van werken. De voldoening die ik had van het relationele model van zorg resoneren nog altijd door in mijn perspectieven op de verloskunde. De relaties gaven mij energie en inspireerde me. Ja, soms was ik moe en wilde niets anders dan mijn telefoon afzetten. Maar dat werd steeds opnieuw goedgemaakt bij de volgende geboorte, het volgende imponerende moment; dat wij als verloskundigen het privilege hebben geïnviteerd te worden een bevalling te begeleiden.

Laat de caseload – verloskunde en persoonlijke continuïteit van zorg je geen zorg geven of bang maken. Het was een prachtig deel van mijn werk als verloskundige, dat ik vaak mis, nu ik ben ingebed in de academische wereld. Het plezier van zo te werken, overtrof altijd de momenten van kwetsbaarheid of twijfel. Zorgen voor vrouwen en hen adviseren en uit de eerste hand zien en horen hoe het werkt of niet werkt voor hen, geeft vorm aan praktijk besluitvorming. Het steeds opnieuw vrouwen ontmoeten die gezinnen vormen is een genot.

Ik moet zeggen dat caseload – verloskunde echt de kunst en de magie van de verloskunde door vroedvrouwen benadrukt, die mij altijd na aan het hart zal liggen. Wees niet bang voor caseload – verloskunde, het is duurzaam, aangenaam en goed uitvoerbaar met de juiste ondersteuning en flexibiliteit. Ik ken collega’s die na 20 jaar zo werken, het nog altijd even boeiend en inspirerend vinden. Net als collega’s met kinderen, collega’s die net afgestudeerd zijn en collega’s die nooit zo hebben gewerkt in een vrije praktijk. De belemmeringen om op deze wijze te werken worden overwonnen met steun- en de wens- en inspiratie te willen slagen.

Wat anderen ervan denken? Zou deze aanpak werken in het Verenigd Koninkrijk? Zou deze aanpak werken als nationale aanpak in bijvoorbeeld Schotland (of Nederland)? Heb je er ervaring mee?
Go well ……

Dr. Susan Crowther is hoogleraar verloskunde aan de Universiteit van Aberdeen, UK.

Vertaling Tine Oudshoorn, verloskundige, n.p. MA.

UK Hermeneutic Phenomenology course & symposium

Course and symposium bookings now open. The 2018 April event is in Aberdeen, Scotland hosted at Robert Gordon University. As at the 2017 event Dr Gill Thomson from UCLAN co-facilitates with me! The 2017 event in Preston was fantastic and we are both looking forward to the 2018 one…. see you there. Information on how and where to book a place for the course/symposium is on the attached posters.

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Ecology of Birth

Last week I spent a day at the University of Humanistic Studies, Utrecht, The Netherlands  attending a symposium:

“Concerning maternity: ethical and existential questions at the beginning of life” hosted by Dr. Inge van Nistelrooij & Dr. Joanna Wojtkowiak.

Every human is brought into the world through the woman’s body, however, there is surprisingly little research conducted on mothers’ perspectives on good care at the beginning of life. The symposium focused on existential concerns at the beginning of life from the perspectives of those closely involved in the care of new life: mothers, fathers and professional caregivers. This symposium was the first part of a two-piece expert-meeting of a new program of research. This 1st symposium posed the question

‘What are existential concerns at the beginning of life?’I was invited to share some of my insights about spirituality, childbirth and existential experience. Needless to say i resonated with this theme! Part of the key note I gave explored the following taken from my chapter  ‘Birth as a Sacred Celebration’,  In (Crowther, S & Hall, J. 2017 Eds.) Childbirth and Spirituality: meaning and practice at the start of life. pp. 15-16. I want to share this excerpt from the chapter and presentation in the hope it will generate some dialogue.

Ecology of birth

There is a wholeness about childbirth which I to refer to as an ‘ecology of childbirth’ which unfolds at each birth (Crowther 2016, Crowther 2014). Yet we need to be cautious of naming something. The notion of an ‘ecology of childbirth’ (see figure 1) and its implications for how childbirth occurs within contemporary maternity systems is used here as a point of departure in our explorations and is not intended to be taken as a fixed and inflexible notion.

An ecology of birth

According to Haeckel (1986) ecology is the science of relationship of living things/beings and their environments. What is key in this definition of ecology is the significance of relationships. I would contend that ecology in relation to childbirth is concerned with multiple relationships. It is an interrelated phenomenon comprising an embodied quality [i], a spatial quality that includes felt-space and physical places of birth, a quality of relationality or being with others, a quality of temporality that incorporates Kairos time (explored later in chapter), a dynamic quality of social-political and cultural context e.g. changing policies and practices informing childbirth. Simultaneously every birth includes a mysterious unspoken quality unfolding in and around the occasion. This ‘ecology of birth’ incorporates ALL types of birth in ALL circumstances.

An ecology of birth is a notion built upon the enigmatic description of Heidegger’s fourfold [ii] (Heidegger 1971/2001), Smythe et al’s (2016) interpretation of the ‘good birth’ and my own research in relation to the existential qualities of lived-experiences of being at the time of birth (Crowther 2014). Reawakening our collective cognisance of an ecology of birth can bring remembrance of how each birth is potentially a joyful celebration of life and our shared natality. I infer a ‘reawakening’ as I fear we have forgotten or covered up our original knowing. In this chapter I adopt a phenomenological and philosophical hermeneutic lens informed by the works of Heidegger (1927/1962), Gadamer (2008/1967), Arendt,(1958) Dilthey, (2002) and O’Byrne, (2010) to present a philosophical interpretation of birth as spiritually meaningful.

[i] Embodied experiences refers to how the body is the medium of our perceptions (Merleau-Ponty 1962/2002). Experience and bodily sensorial sensations are thus inseparable. For example a joyful experience is both our material body, such as tears of joy, as well as the lived experiencing of the joy. As Heidegger (2001) contends we body our experiences, that is to say we embody them.

[ii] Heidegger’s philosophical notion of the fourfold is a central aspect of how we dwell as human beings in all situations we find ourselves. The fourfold has four components: earth and sky, divinities and mortals which are an inseparable unity that cannot be divided into separated components. Each component is interconnected and in the interiority of the other. Heidegger claims that human beings are not only a being in the world, but are always part of this fourfold. For further description read Heidegger’s (2001) Poetry, Language, Thought

(full references given at end of chapter).

Finishing First Year Midwifery

This is such a lovely blog from a 2nd year student midwife at RGU – I just felt compelled to share! Emma, midwifery is privileged to have you join the profession!

RGU Student Blog

This September I finished the first full year of my midwifery course, and so much has happened in that time. I sat an exam, I failed essays and passed essays, I moved into a new flat with 3 fantastic girls, I’ve worked in 3 different hospitals during 4 clinical placements, I set up my own Netflix account and I have delivered 10 beautiful babies.

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Spirituality and Childbirth: meaning and care at the start of life

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.

A four-day Hermeneutic Phenomenology Methodology Course (3-6th April, 2017)

School of Nursing and Midwifery Blog

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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Hermeneutic Phenomenology Symposium April 2017

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!

Caseload midwifery is sustainable: personal example

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!

Background

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…   

Week one

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
Week two.

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
Week three.

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
Week four

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?
Go well

Birth from the Baby’s Perspective

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

MidwifeThinking

Edited and updated: March 2013

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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Embracing the Dionysian Apollonian paradox in maternity care research

“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.complx

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

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.

dionysusDionysus eats the intoxicating fruits

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.

Relational spirituality: personal, spiritual and professional life

Recently I did a workshop exploring 2014 and how I’m going forward into 2015. It was a beautiful thoughtful workshop with a group of like minded others cooperatively inquiring into what it means to be alive and together. I declared 2014 a year of “Relief, success, joyful connections and stuff that needs and beckons attention!” I love the contradictions in that yet feel how 2014 brought challenges that have informed my moving into 2015. I announced that 2015 is a year of “enriched relationships, deepening self-awareness and gratitude for my multitude of choices”.

I am now pondering relationships and what that means to me personally and professionally. What is enriched relationships? There are certainly my professional work based relationships, relationships via social media fora, social/fun connections and family. Yet there is something remaining invisible and ungraspable. The sense of what lies between us all, the mystery of relational connectedness. The moods we find ourselves in gesture to understanding the world. If I’m joyful the world I create around me is experienced vastly differently to a day attuned fearfully. For example arriving at a labour and birth attuning to fear directs my awareness to risk averse tasks, arriving with a feeling of joy draws me into something quite different, something wholly relational in quality. What is this mysteriousness going on between us, in our eye to eye contact, the mutual hug, the knowing smiles, eating together, sharing of stories, of being together…?

Yesterday I had the pleasure of sharing tea and cake with an old client and her 3 children. The mother gave me that extra-long hug and prolonged eye to eye contact infused with mutual positive regard when you just know you are connected on a deep level. The eldest child, Frida, as I was leaving run towards me jumped into my arms and gave a big whopper kiss on the lips. She starts school tomorrow at age 5, I was moved as I glimpsed a memory in her eyes of our first eye to eye glance when she was one minute old.

With this recent experience I wonder what is really going on – is something “always just there” despite my fluid moods which apparently alter my daily perceived realities! I feel something is surely going on between us in every moment. The moments between Frida and her mother were nourishing and extraordinary. There is something between us that beckons. A space of flourishing beyond right doings and wrong doings, notions of right and wrong. A felt sense of spiritual other when we attune consciously together in an intimate encounter, such as at a birth, tender moments with a friend or work colleague, when we sit in a circle (such as at a workshop), read a letter from a loved one. There is something tangible yet unseen in that space between I and You.

These precious and treasured moments I understand as a manifestation of relational spirituality. Although they are never complete they gesture infinite unravelling possibilities. Spirituality is thus not of faraway mystical places of the imagination (could be these realms also) but felt in our embodied experience of being alive together on this earth, in this time. Relational spirituality is felt when we see an old friend for the first time in years yet continue to just “know them”, their circumstances may have changed, their lives altered. However in those moments we are gifted the beauty of what lies quiescent and ineffable between us in our connections.

A beauty often over looked and given no significance in our busy professional and personal “doing” lives. The beauty is at the heart of who we are, our being; it is That which allows us to flourish. Yet this seems to require a certain authentic way of being in the world. The sweet possibility to be vulnerable with self and others in ways that are normally not expressed in everyday life. Someone recently reminded me of a Rumi teaching – “when you seek God, just turn to your friend and look into their eyes” – such a simple technique for dissolving conflict arising from difference or what seems contradictory. The challenge of integrating personal, professional and spiritual life encounters leaves me bewildered at times. The long staff meetings at the university where I work, teaching a class of student midwives, running a busy antenatal clinic, to name a few. Featured image Allowing myself to live through and within the presence(s) around and between us, gifts a certain permission to pause in my “doing” and to simply ‘be’ allowing access to this hidden treasure in life. This opens myself and others I encounter to celebrate and affirm our presence in the world. Such moments I find traverse the different aspects, roles and responsibilities of our lives.

I remember speaking with a student midwife recently who was concerned that she cried with joy at a birth. But why not feel and express joy in our lives? I asked her to share how the birth was special and how it made her feel. It was a beautiful dialogue. The potency of these feelings are embodied and embedded within relationships with others. In this context to be at a birth is profound, stirs us up and brings a depth of knowing not encountered much in our everyday life.

It is not surprising we are touched and moved – sometimes we experience embodied moments of tearful joy. It’s a celebration of our immanent experience of what is divinely sought in our lives. Immanent and transcendental presence in the world manifests in the form of our shared natality. Yet how is it that mortality over shadows natality? We focus copiously on mortality and morbidity avoidance in maternity yet natality sings out to us of newness, potential and endless creativity stretching far beyond our thoughts, protocols and daily activities. Tears of joy and sorrow are to be welcomed. They are embodied expressions of our relational spirituality. They are tears of yearning to feel connected and a symbol of our return from separateness and aloneness.

Spirituality is immanent, experienced in the ever unfolding creativity of creation in our lives with others. Immanent spirituality brings a sense of the sacred into our lives by connecting at once with the transcendent. For example when I am privileged to be at birth I am immersed in the magic of a creative act within creation. Simultaneously I and You are in relation with a vast unconfined unknown time that stretches back and forward meeting in a sacred Kairos moment.

The transcendent for me is beyond form, it is the non-material, otherworldly, unexplainable inspiring felt mystery of life. Participants in my own study and similar studies on spirituality at birth speak of unseen others, ancestors, spiritual otherness and the presence of those yet to come. This immanent-transcendent human experience co-exists, they are not dichotomous.

This living paradox in our lives frustrates our need to understand and have it all wrapped up in logic. This ineffable quality of our lives remains forever unexplainable. Do we need to remain open to further knowing and inquiry? My concern is that we simply avoid such inquiry. Relegating the spiritual explorations in life to a personal ‘hobby’ and dropping spirituality into the too hard basket at work avoids the risk of self-exposure in a revered and dominating “matter-of-fact” technocratic attuned world that would make us feel vulnerable. As Lammi (2008) asserts: “One might expect that if the question of the divine is undecidable, it is a particular kind of question unlike other questions. I would argue to the contrary that this ‘undecidability’ makes it the very paradigm for all questions beyond the merely matter-of-fact” (p. 51). To inquiry and be present to spiritual experiences in our relationships with others allows far more space in our personal and spiritual lives to live more authentically. It is a challenge for sure.

To draw into nearness enriching relationships is to embrace spirituality as relational to all that is seen and unseen. My own research into being at the moment of birth is one such occasion when there is a relational gathering when each there at that moment is touched by mystery. All who gather there willingly and unwillingly reach out and touch mystery. To be touched at birth is to touch seen and unseen realms, to be left vulnerable – physically and feelingly in the sweetest of ways.

So I embrace 2015 and wish you all the magnificence of flourishing enriched relationships and relational spirituality; be courageous, real and vulnerable and let the magic of what dwells between us fill your personal and professional lives.

Further reading:
Heron, J. 2006 Spiritual inquiry, Lulu Press, USA.
Abram, D, 1996 The spell of the sensuous, Vintage, NY
Buber, M. 1996/1923 (Trans) I and Thou, Touchstone books, NY

Mood at Birth and Christmas past and present

As Christmas arrives, a time of reflection for many on a holy birth, I ponder the way we as society attune at birth today. All human experiences are culturally and historically determined, including birth. Birth as with all other human experience and understanding is contextual. As Gadamer contends we are viewing and knowing the world from an inescapable effective historical consciousness. We are in a way continually walking into our past. I argue like others that birth is not purely physiological but enmeshed in its own unique context. Therefore to explore any phenomenon at birth is at once to address all of birth, past and present which at the same time is connected to future possibilities. There are constant hints from history that gesture towards birth as significant fusing with contemporary horizons of understanding and possible futures. That is to say that how we tune into, tune in or attune at birth reveals how birth is understood.

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