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ISSUE 39 MARCH 2018

How to Improve handover Cultivate kindness in midwifery Face antepartum haemorrhage fears

Adoption

t r a

Help, don't hinder, birth mothers

Using

in antenatal care

3 new things

Freebirthing on the rise Wireless obstetric monitoring patch Reď€ ned carbohydrates increase infertility

Help mothers to

breastfeed to natural term


Contents

22

Anterior 3 4

Editor's letter – Sister Lilian ponders midwifery's current crossroad Guest voice: Better handovers are in our hands, says Thembi Kubheka

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Pregnancy ponderings 6 Safe & sensible skincare during pregnancy 8 Facing your antepartum haemorrhage fears 10 Belly talk: Are we eating our way to infertility? •

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Nutritional solutions for birth defects • Side-sleeping during pregnancy cuts risk of stillbirth • Natural miscarriage • Help for heartburn

Birth power

24

28

celebrates its

10TH YEAR

12 Adoption and birth mothers – help, don't hinder 15 Pause4thought: Non-invasive, wireless

in 2018!

'patch' set to change obstetrics monitoring • Midwifery is what midwives do • Upright appeal 16 Time to be kind

Editor's letter

Mom & Baby 18 Baby weaning blueprint 20 Baby steps: Probiotics could prevent postpartum depression • Long-term consequences of C-section • Colic, reux, over-fed, or misunderstood? • Baby acne • Conrmed: Baby-led weaning is safe!

R

ight now, there's loads of excitement, many uncertainties, and some anxiety about the future of midwifery in South Africa. It seems that our profession is, just like our country and the world in general, at a crucial crossroad, hovering on the brink of change. Of course, change also presents the opportunity for rejuvenation. Join Sensitive Midwifery as we wholeheartedly commit to helping design a favourable midwifery future. Every expectant mother also faces excitement, uncertainty and anxiety; midwives are 'with women' not only by virtue of the care they give, but in the emotions they both face! That's good reason to commit to providing sensitive midwifery to all.

Baby knows breast 23 Milky Ways • Ultimate skin-to-skin at the breast Breast assured • No trading exclusive breastfeeding for supposed allergy protection 24 Nursing to natural term

Dimensions 28 Inner healing & power through art • 31 Horizons: The rise of freebirthing • Uncensored birth images on Instagram • Flaxseed oil

Posterior 32 Sensitive Midwifery Symposium 2018 programme 33 Key research references in this issue 35 Last word: When the tool becomes the master;

helps make

Michel Odent talks about his latest book

Editor Sister Lilian Sub-editor Kelly Norwood-Young, Hello Hello Creative Communications Contributors Thembi Kubheka, Prof Joseph Seabi, Margreet Wibbelink, Jane Maasdorp, Kelly Norwood-Young, Dr Michel Odent Snippet research Margreet Wibbelink, Kelly Nowood-Young, Sister Lilian Business manager Alan Paramor Advertising sales Gillian Richards Advertising support Diana Twala Design Gretchen Chamberlain, UltraDesign

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 reect standard obstetric practice, though the publishers and

editorial team set great store by ethical, responsible maternity care. While we rmly 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®

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Connect With Us

Email info@sensitivemidwifery.co.za Call +27 12 809 3342; 071 447 3321 Fax 0866 912 485 Postal address PO Box 11156, Silver Lakes, Pretoria, 0054


Thembi Kubheka is the Operational Manager at Itireleng Midwifery Obstetric Unit (MOU) and holds a post-basic diploma in Midwifery and Neonatal Science. Previously, she worked and gained invaluable experience as a midwife for 22 years.

Better handovers are in our hands

Thembi Kubheka offers her thoughts on why patient handovers don't always work as they should, and how midwives can have a hand in changing this process for the better.

a shift change at a hospital, a proper handover is During essential to the continuity of quality care. Hospital setup

4. Suboptimal handover location Handover is seldom done at the patient's bedside Litigation risks and observing condentiality are said to be the principle reasons for this. However, this takes away the new caregiver's opportunity to observe clinical status in relation to what is said about the patient. Of course, midwives and nurses must always take privacy, dignity and personal feelings into consideration – especially at a bedside handover when neighbouring patients or the woman herself may hear what is said.

is such that intrapartum women will be nursed by different caregivers over the course of a day – and in the case of a complication, possibly even at different institutions. Handovers between colleagues (nurse/midwife or doctor), during shift changes or at patient transfer, paint a picture of the patient – an important process that must be taken seriously. A handover is an explicit transfer – not merely of information but also clinical accountability and responsibility. When this isn't fully understood or appreciated, handover practice is suboptimal, with wide-ranging negative effects.

Reporting to medical colleagues When calling a doctor for an emergency, midwives must give the most relevant and crucial information rst, rather than jumping to provide a potential diagnosis with no supportive information. They may recommend medical management, often even C-section, but neglect to state succinctly what midwifery or nursing management has been implemented. For example, in the case of cephalopelvic disproportion, little information might be given on Baby's descent, moulding, contractions or urinalysis. It's a small wonder then that some doctors don't take midwives and nurses seriously.

Handover shortcomings Improving the handover process during shift changes or to staff at the next place of care requires practitioners to take the following considerations into account: 1. Choice of language The language used during handover is not universal, and should be standardised. In South Africa, we have 11 ofcial languages, but this doesn't mean any of these can be used during a handover. Language should be clear, concise and easily understood by all.

How to improve handover Give relevant, concise but complete and current information. Use ofcial midwifery or obstetric terminology known to all. Pay attention during handover as it's a valuable teaching moment. Always use the SBAR chart (Situation, Background, Assessment and Recommendation) found in the Guidelines for Maternity Care in South Africa: it encapsulates all necessary information and improves standardisation. The use of a handover book should be encouraged. A senior manager should monitor handover and participate when necessary.

2. The use of abbreviations Healthcare workers often use unauthorised abbreviations (for example, 'HOP' for 'head on perineum'). With this comes the risk that the abbreviation may cause confusion or misunderstanding, leading to inappropriate or delayed care. 3. Rushed handover When new caregivers arrive late, tired staff at the end of their shifts are more likely to rush through handover without giving all necessary details. There's good reason that the arrival time of new shift personnel has always been at least 15 minutes before the start of the shift!

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Pregnancy ponderings

Safe & sensible skincare during pregnancy While some pregnant women do just seem to ‘glow', many battle with skin problems ranging from acne to itching to stretch marks; here's how you can help them is a time of immense physiological change and, Pregnancy however nely tuned and harmonious this cascade of changes is, various hormonal and other less well-explained pathways may inuence skin changes. Of the lesions which may develop during the course of pregnancy, physiological changes are most common. Dermatoses and cutaneous infections linked to pregnancy require referral to a dermatologist or experienced complementary health practitioner for specialised treatment.

Combatting common skin conditions The three main precipitating factors leading to the physiological skin changes in pregnancy include changes in circulatory hormones and other mediators secreted by the ovaries and placenta, intravascular volume expansion and compression from the enlarging uterus. While these might be considered normal, they may cause stress for a pregnant woman, and sufcient information and support should be offered. Some less serious skin conditions in pregnancy include these four:

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Pregnancy ponderings

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Itching in pregnancy It is not clearly understood why itching occurs in pregnancy, but it is fairly common, especially on the abdomen and breasts, and sometimes areas like the buttocks, labia, upper arms and thighs too. Mostly it is not serious. Suggest these safe, helpful tips: Use the tissue salt Nat mur, as well as homeopathic calendula. Add a pot of rooibos tea, a cup of Epsom salts, or a handful of bicarbonate of soda to bathwater and powder itchy areas with a light layer of cornour. Stop skincare products for a few days as itching might be due to sensitivity to these – if it makes a difference, choose more natural products. Avoid harsh soaps and laundry products. Increase the intake of foods rich in vitamins A, D and linoleic acid, and add a little unrened extra virgin olive or axseed oil to the diet.

Cut down on red meat and fermented foods like pickles as these increase acidity levels in the body, making one more prone. Eat more fruit and vegetables, and include cooling digestive spices like dill, fennel and mint. Increase water intake to eight glasses a day, and avoid caffeinated drinks. Cleanse the area with a weak solution of rooibos tea. Take the tissue salt remedies Ferrum phos (to help treat inammation safely in pregnancy) and Calc sulph (a safe lymph drainage support remedy), as well as homeopathic calendula, which supports skin health.

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Pigmentation It is common to get various pigmentation marks in pregnancy (also called chloasma or melasma), as well as for freckles and other blotches to become bigger and/or darker. It is generally attributed to an increase in melanocyte stimulating hormone, owing to high progesterone and oestrogen levels. Moles often increase in size too, mostly without any problem, though this needs to be assessed. Darker skinned women and brunettes are more prone. Common pigmentation changes include butterylike markings over the nose and cheeks, brown discolouration around the mouth, increased areola size and development of the linea nigra. Pigmentation marks mostly start in the second half of pregnancy, resolve spontaneously in the months after birth, and are mostly gone by 3–6 months. Some women retain a few, especially on the face. Pigmentation marks cannot be treated during pregnancy because the medications are contra-indicated and the hormonal changes would simply allow them to develop again. Suggest these safe, helpful tips: Avoid prolonged exposure to the sun and always wear sunscreen when exposed. Avoid topical bleaching agents and retinoids during pregnancy but know that these can be prescribed after pregnancy and while breastfeeding in severe cases, though these are not always effective.

Cosmetic caution While most pregnant women are fairly aware of possible negative effects of orally ingested substances on their babies, most don't realise that topical ingredients in the skincare products they use are also absorbed through the skin and might be potentially harmful. Although most commonly used products are considered safe, there are a handful of specic ingredients that should preferably be avoided in pregnancy. Unfortunately, sufcient research on the safety of products in pregnancy and breastfeeding is mostly not available. Professionals should make a habit of being discerning and reading the labels of the products that they recommend to parents, as the presence of harmful ingredients is not always obvious. Ingredients that should be avoided in pregnancy include salicylic acid, retinoids, and phthalates. While soy-based skincare products are not considered harmful to the baby, they have oestrogenic effects and may increase the incidence of chloasma in pregnancy.

Dermatology alert! Various more serious dermatologic conditions may also be triggered or aggravated by perinatal hormonal changes. Should a woman present with a skin rash that does not improve with all the general measures mentioned above, referral to a dermatologist experienced in treating pregnant and lactating women should be considered. Several medical treatments availble for these conditions are not safe to use, complicating treatment further. Conditions to be aware of include: Pruritus gravidarum or intrahepatic cholestasis of pregnancy – a rare skin condition unique to pregnancy that is linked to elevated oestrogen and progesterone levels, which interfere with the liver's efciency in excreting bile salts. This leads to a build-up of bile acids, which can spill back into the blood stream. It normally starts in the third trimester and presents with severe itching on the abdomen, later moving to other body surfaces. If a woman has itching and also feels ill and nauseous, passes dark-coloured urine or light-coloured stools, swelling is pronounced or she seems jaundiced, she should be referred for urgent medical treatment. Pruritic urticarial papules and plaques of pregnancy (PUPPP) – an intensely itching and occasionally vesicular eruption of the trunk and arms, appearing in the third trimester and spontaneously healing within ten days after delivery. Pemphigoid gestationis or herpes gestationis – an autoimmune reaction in pregnancy which, despite the name, is not related to the herpes virus. It presents with itchy, uid-lled blisters and increases the risk for premature birth and small-for-gestational-age babies. This condition needs medical treatment.

3

Stretch marks Stretch marks occur due to tearing of the collagen bundles just below the skin and are mostly attributable to the inherent quality of a particular skin type, though race, diet and hydration of the skin can also play a role. After pregnancy, the stretch marks fade from the reddish or darker-than-skin colour to a silvery or lighter-than-skin colour, which makes them less visible, though they will never disappear completely. Suggest these safe, helpful tips: Use the tissue salt remedies Calc uor and Ferrum phos, three times daily throughout pregnancy, to aid with skin elasticity and strength. Apply a nourishing lotion or oil to the areas more prone, like the abdomen and breasts.

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Acne Acne in pregnancy is quite common, especially in brunettes and darker skinned women, as well as those who have quite an intense nature! Pimples could be distributed over the usual adolescent sites or any part of the body – face, back and upper arms are common. Suggest these safe, helpful tips: Know that relaxation and nurturing oneself is an important part of the solution.

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Pregnancy ponderings

Facing your

antepartum

haemorrhage

fears

Antepartum haemorrhage can easily cause panic; midwife specialist Margreet Wibbelink updates midwives and offers an action checklist to ensure best management

haemorrhage (APH), or bleeding from the A ntepartum vagina in the second half of pregnancy, more particularly

from 24 weeks of gestation, is an obstetric emergency that occurs in 3–5% of pregnancies and is a signicant cause of fetal and maternal death. In South Africa, obstetric bleeding (that's antepartum and postpartum haemorrhage) ranks third as a cause of maternal death, and of the APH component, well more than 60% could be avoided.

Not even all placental bleeding after mid-gestation poses a threat. For instance, a placental edge bleed might occur due to the stretching of the uterus, resulting in slight separation of parts of the outer perimeter of the placenta from the wall of the uterus. In most cases, this bleeding will stop after a few hours and the baby won't be affected. In the hours or days before active labour begins, many women experience benign spotting, but of course all such bleeding should be carefully monitored in the context of any other signs that might indicate APH. The three main causes of APH, which account for almost half of all cases, are: Placenta praevia – when the placenta is implanted wholly or in part into the lower segment of the uterus Placental abruption – when there is premature separation of a normally sited placenta Anatomical placental abnormalities, including vasa praevia It is imperative to establish the amount of blood loss when APH occurs. Denitions of the severity of APH are inconsistent, and often the amount of blood lost is underestimated. For this reason, the midwife or doctor must assess if there are any signs of clinical shock, while estimating the blood loss. Fetal distress or demise are important indicators of volume depletion, according to the Royal College of Obstetricians and Gynaecologists (RCOG), which uses the following classication to dene total blood loss: Spotting – staining, streaking or blood spotting noted on underwear or sanitary protection Minor haemorrhage – blood loss less than 50ml, that has settled Major haemorrhage – blood loss of 50–1000ml, with no signs of clinical shock Massive haemorrhage – blood loss greater than 1000ml and/or signs of clinical shock

Did you know? Up to one-fth of very preterm babies are born in association with APH. The known association of APH with cerebral palsy can be explained by preterm delivery. First trimester bleeding and threatened miscarriage increases the risk of abruption later in the pregnancy, according to a retrospective cohort study from Denmark. Previous C-section and termination of pregnancy are associated with increased rates of placenta praevia, which in turn increases the risk of APH. An observational study conducted in Norway found that women who use folic acid and multivitamins during pregnancy are signicantly less likely than non-users to develop placental abruption. Domestic violence in pregnancy may result in APH, and midwives should keep this in mind as they assess women.

Sussing out simple from serious Sometimes, vaginal bleeding during pregnancy, especially in the rst trimester, is not serious, and can be linked to hormonal changes to the cells of the cervix, placenta implantation spotting, or be caused by local treatable infections or lesions (though cancer of the cervix is serious and requires specialist care). There are also times when the origin of the bleeding is unknown. Spotting after sexual intercourse is fairly common and mostly harmless.

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Pregnancy Pregnancy ponderings

Avoiding APH complications is key

APH action checklist for midwives

The possible complications of APH are mostly extremely serious and prevention is what all maternity practitioners should strive for. All pregnant women should be informed during antenatal care that any vaginal bleeding is potentially serious and requires immediate attention. Providing excellent antenatal care with the principles of BANC Plus in mind, ensuring increased professional awareness of APH, improved transportation for women from outlying areas to emergency care centres, and improved nutritional status are all ways to prevent or lessen the impact of APH. The complications of APH include: Maternal complications such as malpresentation, premature labour, postpartum haemorrhage, shock, retained placenta, anaemia, higher rates of C-section, peripartum hysterectomy, coagulation failure, puerperal infections and even death. Fetal complications such as premature delivery, low birth weight, intrauterine death, congenital malformations and birth asphyxia leading to NICU admission. If a pregnant woman presents to her midwife or doctor with spotting, but is no longer bleeding, and placenta praevia has been excluded after a reassuring clinical assessment, she can go home. However, all women with vaginal bleeding, which is ongoing or heavier than spotting, should remain in hospital at least until the bleeding has stopped.

Use this handy guide if you face APH: Ensure you have her full history – previous C-section miscarriage or termination; bleeding in rst trimester; suspicion of placenta praevia, abruption or anatomical disorders; if she is in premature labour. Be calm, assess constantly and reassure your patient. Call for immediate help and transfer to a Level 3 hospital if applicable. Assess the blood loss by visualisation. Observe for signs of clinical shock and commence emergency treatment protocols. Assess for abdominal tenderness with gentle palpation – contractions will be revealed; a tense or 'woody' feel to the uterus indicates a signicant abruption; a soft, non-tender uterus may suggest a lower genital tract cause or bleeding from placenta or vasa praevia. Avoid vaginal examination if there is any suspicion of placenta praevia – scan evidence, a high presenting part on abdominal examination, or the bleed has been painless. See references on page 33

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Register now


Pregnancy ponderings

Bellytalk Nutritional solutions for birth defects

Are we eating our way to infertility?

A woman's nutritional state before and after conception has been widely accepted as an important factor in fetal development. One recent study has found a correlation between low levels of a coenzyme called nicotinamide adenine dinucleotide (NAD) and congenital malformations, particularly in the rst trimester of pregnancy, when an embryo's organs are developing. NAD is one of the most important coenzymes found in all living cells, and synthesis of NAD is essential for energy production, cell communication, and DNA repair. Since the body's ability to make NAD is aided by vitamin B3 (niacin), researchers noted that a NAD deciency could be resolved through niacin supplementation. Sources of vitamin B3 include foods that contain niacin, such as turkey, chicken, grass-fed beef, green peas, liver, mushrooms, peanuts and broccoli. Most prenatal multivitamins also contain niacin. However, the results of this research suggest it's best for women to make sure they have adequate levels of vitamin B3 in their diets before becoming pregnant, and to ensure their prenatal supplement includes this important nutritional element. The recommended daily intake of niacin for pregnant women is 18mg per day.

There are many factors that could be contributing towards a couple's inability to conceive. Diet is an always important consideration. A study done on dietary carbohydrate intake in relation to risk of ovulatory infertility concluded that the amount and quality of carbohydrates in the diet may be important determinants of ovulation and fertility in healthy women. The researchers state that these ndings are consistent with other evidence suggesting a link between the impact of insulin and glucose metabolism on fertility. For women trying to get pregnant, eating fewer rened carbohydrates (such as sugar, pastries, pasta, cereals and sweets) is sensible as it may also improve fertility. Chavarro et al, 'A prospective study of dietary carbohydrate quantity and quality in relation to risk of ovulatory infertility', European Journal of Clinical Nutrition, 2009, 63:78-86

Hongjun, S et al, 'NAD Deciency, Congenital Malformations, and Niacin Supplementation', The New England Journal of Medicine, 2017, 377:544-552

Side-sleeping during pregnancy cuts risk of stillbirth Stillbirth is devastating for both parents and professionals. A 2017 UK study looking at 1 024 pregnancies, of which 291 ended in stillbirth, has conrmed that a supine sleep position during late pregnancy is associated with late stillbirth. The Midlands and North of England Stillbirth Study (MiNESS), conducted in 41 maternity units, is the largest of four studies to examine the correlation between maternal sleeping practices and stillbirth risks. The research showed pregnant women who go to sleep on their backs to be 2.3 times more likely to experience a stillbirth after 28 weeks' gestation, compared to women who fall asleep on their left sides. If pregnant women go to sleep on their sides during the third trimester, MiNESS estimates that 100 000 babies could be saved internationally every year. Expectant mothers should be advised to be aware of their sleeping positions, and to put pillows behind their backs to encourage side-sleeping throughout the night. Heazell, AEP et al, 'Association between maternal sleep practices and late stillbirth – ndings from a stillbirth case-control study', BJOG, 2018, 125:254-262. Accessed at: http://onlinelibrary.wiley.com/doi/10.1111/14710528.14967/full Tommy's, 'Sleep position and stillbirth risk – press release'. Accessed at: https://www.tommys.org/pregnancy-information/sleep-side/sleep-positionand-stillbirth-risk-press-release

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Pregnancy ponderings

Bellytalk Natural miscarriage Miscarriage is a common, albeit difď€ cult, reproductive event. Most people will experience miscarriage medically, having an ultrasound and blood tests, and then discussing their medical options. In many ways, this resembles the medicalisation of birth. While complications can occur for some miscarriages, many of them, like births, do not actually require medical intervention – and it is certainly possible for a woman, who wants to follow a more natural route, to do so. Here's what women need to know about the process of physiological miscarriage: It may take a few days or even weeks. Miscarriage will start with light bleeding and mild cramping, which will become heavier and more intense within a few hours or days. Breathing exercises, warm baths, and other relaxation techniques will ease the physical process. They should ensure that they have emotional support both during and after the miscarriage. Of course, letting a midwife or doctor record information pertaining to the miscarriage is also important, to ensure that future care takes this into account. Austin, J, 'Physiological Miscarriage at Home', 7 November 2017. Accessed at: http://www.birthtakesavillage.com/natural-miscarriage-at-home/

Help for heartburn Interestingly, women who are driven, hot-headed or tense tend to suffer more from heartburn and indigestion in pregnancy than those who are more relaxed! They should: Eat smaller meals more regularly. Avoid eating for three hours before sleeping or lying down. Reduce spicy, fatty and rich foods considerably. Take a homeopathic remedy for heartburn, or the tissue salt Nat phos. Add a few drops of peppermint essence to a cup of hot water, and sip that slowly. Chew a mint leaf or a small piece of liquorice.

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Adoption and birth mothers Help, don't hinder There are many reasons women choose adoption, and there are even more effects of this choice on birth mothers; Educational Psychologist, Professor Joseph Seabi, weighs in on how health professionals can help ease the process

Joseph Seabi, Educational Psychologist, and Associate Professor in the Department of Psychology, School of Human and Community Development, of the University of the Witwatersrand

is important that health professionals recognise that they I thave an important role to play in the adoption process.

Midwives who understand adoption and its effects can make a signicant difference to a woman's experience of her pregnancy and the subsequent sense of loss that follows giving her baby up for adoption.

Adoption loss Research clearly shows the impact of adoption loss on birth mothers. Whatever her reasons for deciding to give her child up for adoption, the birth mother may continue to experience ambivalent feelings regarding the soundness of her decision. She may feel guilt, regret, self-blame, and experience enduring responsibility and protectiveness for her child. These thoughts and feelings can compromise her self-esteem and increase a sense of hopelessness, powerlessness, and despair, making it more difcult to return to adequate functioning. For some birth mothers, to recover from the loss feels disloyal to their child. A large body of research indicates that for a mother, the adoption of her child produces profound and protracted grief reactions, depression and an enduring preoccupation with and worries about the welfare of the child. The placement of a child for adoption and the experience of loss that accompanies it represent a major life stressor for a woman. It is perhaps one of the most serious losses she will ever face and one complicated by its ambiguous nature. In the case of adoption, the birth mother experiences ambiguous loss – one that is not nal, due to the fact that her child is psychologically present but physically absent. Researchers have indicated that ambiguous loss is more difcult to resolve than permanent loss and the greater the ambiguity surrounding the loss, the more difcult it is to master. A child surrendered for adoption is still living but in another family, and the enticing prospect of reconnecting is ever present. Birth mothers may or may not have information about how their children are doing and may worry about their ongoing well-being.

Closed vs open adoption In the past, closed adoptions (non-disclosed) were largely used, whereby birth mothers were instructed to go on with their lives as if nothing had happened. Closed adoption is characterised by sealed legal records with no contact between birth parents and adoptive families. These beliefs and practices regarding adoption have been disputed by recent studies. On the other hand, open adoption – also known as fully disclosed adoption – involves contact, communication, and/or information sharing between a child's adoptive and birth families. Contact between adoptive and birth families is becoming more common across all types of adoption, accelerated by social media and new technologies. In an open adoption: The birth mother may help to choose, and perhaps even meet, the adoptive couple prior to the child's birth. The adoptive family may provide the birth mother with pictures and updates about the child. There may be ongoing personal contact between the birth mother and the adoptive family through an agency or personally. The people in contact can include the adopted child and any combination of adoptive and birth family members, which collectively is regarded as adoptive kinship network.

Continued on page 13

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From adoption secrecy to support The possibility of experiencing disenfranchised grief adds another layer of complexity to recovery from adoption loss. Disenfranchised grief occurs when the person experiences loss that is not or cannot be openly acknowledged, publicly mourned, or socially supported. Loss is not only a psychological process but a social one as well, and when an intense loss is not acknowledged by others, the individual does not receive much-needed understanding and social support, which compromises the grieving process. A consistent nding in studies of women who have relinquished children in condential adoptions, particularly for those in the era of secrecy, is that a signicant number have complicated, ongoing grief reactions, with mental health issues including prolonged mourning, depression, diminished selfesteem, anger, restless anxiety, somatic symptoms, guilt and shame, and post-traumatic stress disorder symptoms. Furthermore, child relinquishment has been shown to impact the social relationships of birth mothers, including those with parents, peers, romantic partners, and future children. Unlike closed adoption, the benecial effects of open adoption have been documented, and positively impact the birth mother's attitudes about and adjustment to the loss of her child. Women in open adoptions commonly display greater satisfaction with the placement arrangement than those with less information about and contact with their child and the adoptive family. They also report better physical and emotional health in the rst year post-placement and in their current life.

South African adoption statistics According to the National Department of Social Development in South Africa: There were 14 803 legal adoptions registered in South Africa between 1 April 2004 and 31 March 2010. That amounts to more or less 2 400 adoptions per year. It is estimated that 14 599 children were placed in stateowned children's homes in 2009 while 668 000 children were orphaned in 2007 in South Africa.

Good midwifery matters to birth mothers The World Health Organization (WHO) recommends that physiological and psychosocial assessment should commence during the rst antenatal visit as part of a comprehensive assessment, at which time the midwife should elicit the medical, surgical, social, psychological and obstetric history, which may affect the outcome of the pregnancy. Of course, midwives use their knowledge, skills and available evidence in order to assess any potential risks associated with pregnancy throughout the childbearing process, and a full assessment allows them to provide care and appropriate intervention to women in need. The psychosocial support midwives provide minimises maternal distress, promotes a positive attitude towards childbirth, inspires healthier lifestyles and discourages behaviours such as smoking, substance abuse and poor nutritional intake, thus promoting a healthier pregnancy outcome. In addition, midwives should permit and encourage all women to share their feelings, and provide counselling, support and care based on individual needs. When possible problems with rearing a baby proves to be on the cards, a midwife can either make sure that an expectant birth mother receives counselling from an appropriate support person, or provide her with information about her options, such as: Termination of pregnancy Adoption Encouragement of family involvement 13 Guidance on applying for social support grants

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Antenatal teachers and midwives! Feel free to share this online publication from the Sister Lilian Centre with all pregnant women in your care, free of any charge

Adoption requires sensitive support Midwives must understand that it is essential that birth mothers are not pressured to relinquish their children, nor should they decide on adoption without receiving adequate support and preparation. A psychologist specialising in adoption should provide counselling. Support should ideally be provided throughout a woman's pregnancy, the placement process, and for years after the adoption. To effectively grieve their loss, women need understanding, validation, and support from those around them, most especially from their family and friends. For this reason, it is essential that adoption professionals involve the birth mother's support system (that is, her family and friends, and even her co-workers) in the counselling process. Research indicates that it is crucial for health professionals, including midwives, to explore pregnant women's feelings about pregnancy, childbirth and motherhood and to give women who express fear an opportunity to discuss this, as part of providing comprehensive antenatal care. These are phases in life that create demands on a woman's ability to adapt physically, psychologically and socially. It has been well documented that anxiety and extreme emotions might lead to complications, such as preterm labour and delivery. How much more should this be a consideration for women who feel compelled to give up their children for adoption? A psychosocial risk assessment on these pregnant women Is even more important. Understanding that child relinquishment is a major life stressor with long-term ramications for women's emotional well-being is the rst step to health professionals being able to provide sensitive care to birth mothers. Where possible, midwives should encourage mothers to consider open adoption over closed adoption, as this allows for contact that is consistent with the expectations of all involved parties, and accommodates negotiated change as life circumstances evolve and the adopted child develops.

Adoption resources SA Adoption provides a list of resources including support groups across South Africa (www.adoption.org.za). Some other sources of support and information are: Rainbow Support Group (021 638 3127) National Adoption Coalition of South Africa (0800 864 658, www.adoptioncoalitionsa.org) Abba Specialist Adoptions & Social Services (012 342 6145, www.abbaadoptions.co.za) See key references on page 33

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Non-invasive, wireless 'patch' set to change obstetrics monitoring Four years after the traumatic birth of her second child, and knowing that the uncomfortable, restrictive CTG monitoring used during her labour added to her anxiety, mechatronic engineer Sarah McDonald has developed a less invasive way to monitor women in labour. McDonald's real-time monitoring pregnancy patch – named Oli – has recently received a share of AU$6.61 million in funding aimed at bringing the device to market. The wireless patch not only allows greater ease of movement during labour, but also has the potential to cut unnecessary intervention rates. With the information this technology provides, caregivers will be better able to predict an individual's ability to progress, and be more able to time and tailor necessary interventions to suit each patient. Aubusson, K, 'Pregnancy patch that aims to cut interventions wins NSW government Medical Devices Fund grant', 30 August 2017. Accessed at: http://www.smh.com.au/national/health/pregnancy-patch-that-aims-to-cut-interventions-wins-nsw-government-medical-devices-fund-grant-20170829-gy6h7y.html

Midwifery is what midwives do ‘Obstetrics is what obstetricians do, midwifery is what midwives do, and maternity care is what we all do. We have to retract the language that physicians and the populace have inserted into the English language that normalizes obstetrics, thus making midwifery hidden, an “alternative”.’ This statement, made by the editor of the Journal of Midwifery & Women’s Health in a Reader Survey, will resonate with many a midwife. The language we use is important. Using the right wording to describe the distinct models of care provided is essential – not only for professional dialogue, but also for women to make informed choices about their healthcare provider options. Likis, FE, ‘Midwifery is not Obstetrics: The Importance of Precise Maternity Care Language’, Journal of Midwifery & Women’s Health, 2017, 62(4):395-396

Upright appeal

encouraged and assisted to assume whatever positions they choose. What are we waiting for? Let’s implement this evidence from this day on, in every birthing room in the country and world!

Home-birthing midwives will conrm that they, in most instances, allow their clients freedom of movement during labour and birth, and that they have noticed that women in labour almost never lie down on a bed by their own choice. The expectation that women would labour and birth on a bed emerged when the medical model of maternity care became entrenched in society. There is no evidence to support this birthing position – it is purely because of doctors’ (and possibly some midwives’) preference. To think that this is how birth got to where it is now! Simultaneously, there is much evidence from multiple sources that indicates that women should NOT lie down during labour and birth. Lawrence et al (2013) state that there is clear and important evidence that walking and upright positions in the rst stage of labour reduce the duration of labour, the risk of caesarean birth and the need for epidural – and do not seem to be associated with increased intervention or negative effects on mothers’ and babies’ well-being. Based on their ndings, they recommend that women in low-risk labour should be informed of the benets of upright positions, and

Lawrence, A et al, ‘Mothers’ Maternal positions and mobility during rst stage labour’, Cochrane Database of Systematic Reviews, 2013, Issue 10. Available at: http://onlinelibrary.wiley.com/ doi/10.1002/14651858.CD0039 34.pub4/pdf/abstract

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Time to be

kind

The ancient Greek philosopher Plato said, 'Be kind, for everyone you meet is ď€ ghting a hard battle.' Sensitive Midwifery Magazine founder and editor Sister Lilian asks: is kindness a value held by midwives?

on kindness is indeed quite a philosophical thing A discourse and, over many centuries, much has been reected on,

Born to be kind

argued over, and written about the topic. Chances are, most modern-day midwives will simply gloss over kindness as an obvious moral value, something to think about in spiritual terms maybe, and not expect to read about it in a midwifery magazine. However, Sensitive Midwifery (the Magazine and Symposium) believes that to be 'sensitive', a midwife needs to be kind. In fact, kindness could be the single approach that could likely overnight change the face of birth care provided to women for the better, and effect huge, positive change to perinatal outcomes. Much has also been written about the importance of alleviating anxiety during labour, in support of inherent physiological processes which in turn facilitate a physically and emotionally positive birth experience. It requires a very small stretch of the imagination to conclude that kindness by midwives to women in labour will reduce anxiety. What's more, it's easy to talk the talk when it comes to kindness, sagely agreeing that kindness is a good thing, but when raised as a practical step needing addressing, many a midwife appears to be more focused on the time urgency they experience in the workplace. A harried environment doesn't make it easy to take the time to be kind, it appears!

Most people would say that the difference between a kind and an unkind person is obvious, and the consensus is often that a kind person is someone who helps others spontaneously and regularly, and that this trait is inherent in them. Interesting research done after the murder of 28-year-old American bar manager Kitty Genovese in 1964, led to the term 'bystander effect' being coined, as many people who witnessed the event didn't come to her aid. The theory was that help is less likely to be forthcoming if there are strangers nearby; that a type of inertia results and that group members assume that someone else will take responsibility. Even more relevant is research that showed that theology students, who had been asked to lecture on the subject of the Good Samaritan, were less likely to stop to help someone in trouble if they were in a hurry! However, research has also revealed that there is always a small number of people who do stop to help, no matter the circumstances, even when factors designed to discourage helping behaviour are built in to the studies. Apparently, some people just are kind.

Continued on page 17

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Can kindness be learnt? While helpfulness is central to kind behaviour and kindness appears to be something you are born with, there's more to it than meets the eye. A kind person shows respect to others, listens authentically, and is non-judgemental. All these traits can be cultivated, even if they come with greater difculty to some. And so, kindness can be strived for – and attained. There must be few such busy, demanding work situations as faced by midwives in a labour ward in a busy referral hospital. Here too, there are always some midwives who are more likely to be kind to the women in their care than others. And yet, surveys done at Sensitive Midwifery Symposium over the years consistently reveal that midwives seldom wish for a different job, and if they do, they would still select one of the caring professions. It would seem that the desire to help is strongly ingrained in midwives. Surely then, the many reports of midwives being rude, abusive and unkind to women in labour, can be replaced by stories of kindness? Most midwives would agree that women in labour are facing a challenging time in their lives, and could do with some of that kindness Plato spoke about! To become kinder, midwives should: Know what it's doing for their clients: See things from the client's perspective, imagining how you would like to be treated, and do at least one of those things at each interaction. Make kind gestures a habit: Greet and address every couple respectfully, reassuring them; use gentle touch while talking to women in labour; and do at least one thing for each client that will make her feel less anxious. Review their actions regularly: Make kindness-analysis part of team case studies; ask at the end of each shift if you have not only been professional to every client that day, but kind too; and resolve to show a little more kindness the next day. When the day is difcult, the work overwhelming and the resources few and far between, remember that the pursuit of kindness is not a luxury, but the human thing to do. In addition, kind midwives are helping achieve the greater good of improved birth outcomes, because kindness allays anxiety, which allows endocrine physiology to facilitate better birth for mother and baby. What's more, soon increased kindness will become part of you and even reduce your own stress levels, making your work that much more enjoyable, because although being kind is not about you, it comes back to you and initiates a positive feedback cycle. It's not more time you need to be kind – it's the will to be kind that counts! See reference on page 33

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Mom & Baby

Baby weaning blueprint

Baby suddenly demands more bottle or breast feeds Baby may simply need more milk (especially if she is under six months), so Mom should rst try to increase the number or length of feeds for at least a week. If Baby is still dissatised, it might be time to introduce solids, unless there is another explanation, like teething or stress in the family. Everyone says Baby is old enough Age is an inaccurate indicator! Most babies don't need to start solids before six months. Milk is food, and Mom should let Baby take the lead in weaning. Baby is teething Teething often precedes an interest in solid food, maybe because there is a connection between teeth and eating! Baby shows interest in parents' food This is an indicator that Baby will soon be ready for solids, although at rst, Baby will only do this to sample the food.

When to offer a baby foods other than milk should be a simple affair, but it's often complicated and disrupted by clinic sisters, doctors, family and friends, maintains Sister Lilian ften, early baby and child feeding becomes a power struggle between Baby and her parents. Not only is this O simply not worth it, but the seeds for eating disorders may be laid down too. In the rst six months, milk, particularly breast milk, can full all of Baby's nutritional needs. From six to 12 months, most babies will start showing an interest in food, some more than others. Baby-led weaning is consistently easiest, and simply involves following a healthy baby's cues that he is ready to try food. Milk is also still very important, and this phase is more of an experiment in taste and texture of food than anything else! From one year, milk will gradually play a less signicant role, though there is no need for Mom to limit breast milk intake.

When Baby really is ready, guide parents as follows: Offer rst foods between milk feeds, when Baby is hungry but not ravenous, and is in a good mood. The optimal digestive time for rst meals is between 10am and 2pm. Increase meal portions slowly (over days or weeks), and don't give more when Baby indicates that she is comfortable. Introduce new foods one at time, watching out for adverse reactions. Add a second meal after about four to six weeks, and a third meal six to eight weeks later.

When to wean There simply is not one correct age to introduce solid foods. Make sure you give wise advice and take the following into account:

Continued on page 19

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Mom & Baby

Baby's rst foods

Advising moms of picky eaters

Baby's age and instinctive food preferences will play a role in the selection of starter foods. Initially, weaning is more about Baby getting used to food than it is for nutritive value. As long as the food is healthy, there's no reason for parents to stress. The three main food groups for starter foods are: Fruit Fruit is healthy and easily digested – ideal for a rst food. Ripe, seasonal fruits can be nely grated or puréed (no cooking required) and from six months, can be cut into nger food pieces. Vegetables Also an excellent rst food option, veggies simply need to be lightly cooked or steamed, and can be served as a purée or nger food. Butternut, carrots, squash and pumpkin work well initially as they are easily digested. From about eight to 10 months, as Baby's digestive system matures, add sweet potato, potato and nely chopped greens like spinach and broccoli. Processed baby cereals After eating rened cereals, many babies become constipated or 'mucousy', and may develop skin rashes, making this the least advisable choice of rst foods. Maize and rice cereals are generally less problematic; wheat cereals and those with milk solids are more so. While some babies might sleep more soundly as a result of cereal introduction, many more don't, so don't spread this myth!

Some little ones will go through phases of eating just two or three foods at a time. Many also eat far less than you or the parents would like, and yet, they still grow well. Remember, a baby or young child's tummy is small – about the size of her clenched st. The family's eating history should be taken into account too – small parents with small appetites tend to have similar children. If Baby simply refuses to eat, parents should take the pressure to eat off her for a few weeks. Chances are that solids have been introduced too soon, and Baby is building up negative associations with food. When Baby starts solids again, allow her to help herself to healthy food options. If Baby is thriving, it is a clear indication that she is eating enough. If a baby is not thriving, supplementation may be needed; Calc phos and Silicea are two excellent tissue salts for this.

No-nos and go-slows Babies and toddlers are often natural 'grazers', preferring to snack throughout the day. The parents' task is to provide their little one with healthy snacks. These cautionary guidelines should also be taken seriously in the early stages of feeding: Do not add sugar, salt or butter to a baby's foods. Never force a baby or child to eat. Do not give a heavy meal at night. Supper should be at least two hours before bedtime. Never offer unhealthy snacks like biscuits, crisps and sweets. Do not add cereal to a baby's bottles. Excessive quantities of non-human milk will affect Baby's appetite for food, and parents should be aware of this from one year. Breastfeeding can continue unlimited, but allow Baby to prompt feeding times. Restrict dairy products, as little ones are often allergic to these. If acidic fruits like oranges, guavas and strawberries trigger rashes, remove them from the diet until after two years. Unripe bananas may cause constipation. Parents should give fruit separately to other foods as fruits are more quickly digested and if they are held back in the stomach by denser foods, may start fermenting and cause digestive discomfort (often wrongly thought of as an allergy to those fruits). Giving just one fruit at a time is also easiest on Baby's digestion. Many babies are allergic to eggs, and battle with foods high in sugar and wheat.

19


Mom & Baby

Babysteps Probiotics could prevent postpartum depression There's growing evidence to show that the community of bacteria (gut microbiota) living in the intestine might be very important for improving mental health. A recent study discovered that women who received Lactobacillus rhamnosus (HN001) during pregnancy and postpartum, had signicantly lower depression and anxiety scores in the postpartum period. The researchers state that this probiotic may be useful for the prevention or treatment of symptoms of depression and anxiety postpartum. Slykerman, RF et al, 'Effect of Lactobacillus rhamnosus HN001 in Pregnancy on Postpartum Symptoms of Depression and Anxiety: A Randomised Double-blind Placebo-controlled Trial', EBioMedicine, 2017, 24:159-165.

Long-term consequences of C-section Many practitioners and women seemingly continue to ignore the risks of C-section and minimise the negative, long-term consequences. These include infection; chronic pain; difculty with bonding and breastfeeding; maternal and neonatal injury and death; newborn respiratory problems; and problems during future pregnancies, including higher risk of uterine rupture, ectopic pregnancy, preterm delivery, placenta praevia, placenta accreta, placental abruption that may necessitate hysterectomy, and increased incidence of postnatal depression. It's incumbent on midwives to spread awareness of this when educating pregnant women. Davis-Floyd, RE et al, Birth Models That Work, University of California Press, 2009

Colic, reflux, over-fed, or misunderstood? Most babies cry to convey discomfort they can't yet verbalise. Many posit milk, which invariably seems more than it is. These realities often underpin many a faulty colic or gastro-oesophageal reux (GOR) diagnosis! An infant may have colic if he has one or more symptoms like excessive wind, tummy cramps, feeding problems, insatiable hunger and either incessant crying or crying associated with feeds. He may have GOR if he constantly posits or spits up milk without effort after and between feeds, accompanied by a few other typical symptoms mostly due to irritation of the mucosal lining of the oesophagus by the regurgitated acidic contents of the stomach. Far more babies are, quite simply, overfed or misunderstood. This causes discomfort, spitting up, or crying more than expected. Yes, if one or more close family members have a weak digestive system, babies might be more prone to colic or reux. This also goes for babies born prematurely; those who had a traumatic birth or C-section; rst babies of anxious new moms; those constantly handled by strangers; and those frequently left alone in the nursery. But mostly, the answers are quite simple. It's about not forcing any baby to drink more than they want to at any one feed (whether breast or formula milk), nor withholding milk feeds when they are obviously hungry. It's also about understanding that babies need sensitive care from, and close contact with, their primary caregivers. All babies are individuals and individualised advice must be given when symptoms make you think it's colic or GOR.

20


Mom & Baby

Babysteps Baby acne 'Our little one was born with baby acne; he is now three months and it's still not better. I've been told to put him on cortisone, but what about the side-effects? Please help!' How often have babycare advisors heard this one? 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 on their cheeks at about two to four weeks of life. The pores in this area are easily blocked until the skin function matures. Milia is not serious and generally resolves spontaneously by three months. No specic treatment is needed but offer moms these tips as a healthy alternative to cortisone creams: 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. Also remind mothers that what goes in must come out. The skin is an excretory organ, and often reects an unhealthy diet. She should breastfeed rather than give formula milk, and reduce or avoid rened, animal proteinrich, processed, additive-rich foods in her diet. Dairy and grain products, and processed meats are common triggers of acne in babies being weaned onto foods, so give Baby more fruit and veg, and fewer grain and dairy products.

Conrmed: Baby-led weaning is safe! 'New research suggests that letting babies feed themselves solid foods from as young as six months does not increase the risk of them choking, compared to spoon-feeding them. Sensitive Midwifery is delighted that at last there seems to be sensible research pertaining to introducing weaning foods, after years of maintaining that baby-led is precisely the only common sense way to do this. Why make difcult what could be easy – and safe? Swansea University, 'Babies that feed themselves have no increased risk of choking, study suggests', ScienceDaily. Accessed at: www.sciencedaily.com/releases/2017/12/171207094943.htm

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Ultimate skin-to-skin at the breast Breastfeeding is likely to go better when a baby is nursed skin-toskin, and this feeds into all the other beneď€ ts to be derived from continual skin-to-skin contact between a mother and newborn. Stress is reduced and oxytocin levels soar. Babies stabilise faster and cry less. High oxytocin levels are good for mothers, too. Human and animal studies tell us that oxytocin activates positive changes in mothers' brains to reduce stress, promote healthy social connections and prime reward centres to imprint pleasure with caring for her newborn. Kangaroo Mother Care (KMC) is one of the ways nature ensures that a mother and child get off to a healthy, bonded start. When a baby is born by caesarean section, KMC may be one of the most effective tools to compensate for the lower hormone levels associated with a C-section. Following a C-section, continual skin-to-skin and hourly breastfeeding is recommended. Bell, A et al, 'Beyond labor: the role of natural and synthetic oxytocin in the transition to motherhood', Journal of Midwifery & Women's Health, 2014, 59(1), 35-42 Leng, G et al, 'Oxytocin and the maternal brain', Current Opinion in Pharmacology, 2008, 8(6), 731-734 Malloy, ME, 'The Mindful Cesarean', Midwifery Today, 2017, 121. Available at: https://midwiferytoday.com/mt-articles/the-mindful-cesarean/

Breast assured

It is mostly providing low-tech care that makes the most profoundly positive difference as a baby develops. What could be more low-tech than nursing a baby? Besides supplying all of a baby's nutritional needs, and contributing in a huge way to his optimal physical development, the nurturing effects of breastfeeding have been shown to have far-reaching psychosocial and mental wellness effects. In turn, this sets the base for vibrant future personal development, self-esteem and well-being. Now that's something midwives and nurses can be proud to facilitate!

No trading exclusive breastfeeding for supposed allergy protection A frequent narrative among allergists is that introducing so-called 'allergy foods' (wheat, dairy, eggs, for instance) to a baby from as early as four months will make him less prone to allergies as he grows, rather than delaying their introduction, along with all solids, to six months. This despite the widespread evidence and international recognition of the importance of exclusive breastfeeding for at least a six-month period, and many mothers' experience of the adverse effects babies have from 'allergy foods'! Maybe the allergists of the world should take note of the many positive effects of exclusive breastfeeding for six months before they make recommendations that could harm generations of children, their mothers, and public health at large. A Cochrane review found that these exclusively breastfed infants experience less morbidity from gastrointestinal infection than those who are mixed breastfed as of three or four months, and there were no deď€ cits in growth among infants from either developing or developed countries. Mothers of exclusively breastfed infants have more prolonged lactational amenorrhea, which ensures they have optimal recovery time from birth, and that there is less of a burden from having many babies in rapid succession on public health provision in resource-strapped countries. It was concluded that the available evidence demonstrated no apparent risks in recommending, as a general policy, exclusive breastfeeding for the ď€ rst six months of life in both developing and developed-country settings. Kramer MS & Kakuma R, 'Optimal duration of exclusive breastfeeding', Cochrane Database of Systematic Reviews, 2012, Issue 8 DOI: 10.1002/14651858.CD003517

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Nursing to natural term For midwives, the importance of natural gestational term is thankfully gaining credence, but, as experienced La Leche League Leader Jane Maasdorp asks, did you know that the natural course of breastfeeding is just as important? and true story was doing the rounds amongst A delightful delegates to the La Leche League (LLL) International

Objective biological measures to determine natural term Using an evolutionary perspective, and examining a number of life-history variables in relation to lactation amongst non-human primates, anthropologist Katherine Dettwyler has tried to determine the 'hominid blueprint' for what might be the physiological norm for the duration of breastfeeding in humans: Variable

conference at the Washington Hilton in 1997. A family checking in at reception was asked politely by the clerk if he could nd out some rather personal information: was the 12-year-old son carrying the bags and suitcases still breastfeeding? 'Oh, no,' the surprised mother replied, 'But what prompted your question?' The man explained that – in training sessions in preparation for the arrival of families from all over the world – the staff had been warned that they may see 'older children breastfeeding'. In his West African home country, it was usual for children to be nursed until the age of seven or eight years so, to him, this almost-teenager could perhaps have been an 'older breastfeeder'. Of course, the American trainer had meant that babies over six months of age at the breast may present an unusual sight!

Ideally, Baby takes the lead Such differences in the duration of breastfeeding between cultures and throughout history have been well-documented, and would not be a curiosity for LLL members who had access to stories from mothers worldwide, helpful references like Norma Jane Bumgarner's Mothering Your Nursing Toddler, and the benet of one of the guiding principles of the organisation: 'Ideally, the breastfeeding relationship will continue until the child outgrows the need.' Dr Ruth Lawrence suggests that 'weaning is rarely childinitiated until age four'. Breastfeeding until about this age was – and still is – common in many parts of the world. Unfortunately, however, unquestioned 'rules of thumb' for a far earlier end to breastfeeding have been imposed in some cultures, and by medical and other experts, but have not been based on evidence about what is biologically normal or optimal.

Duration of breastfeeding

Quadrupling of birth weight

Males: 27 months Females: 30 months

Attainment of one-third of adult weight

4 to 7 years; males longer than females; dependent on family and population body sizes

Adult female body weight calculation

2.8 to 3.7 years

Gestation length

4.5 years minimum, based on closest primate relatives where duration of breastfeeding is more than six times the length of gestation

Eruption of rst permanent molars

About 5.5 to 6 years, which coincides with achieving adult immune competence

Dettwyler concludes that 'taken together, these data suggest that for human children – who have relatively huge brains, grow very slowly, and end up as large-bodied adults – the natural length of breastfeeding is between two and a half and seven or more years', and that long-term breastfeeding 'allows for normal development of the child's brain, facial structure, immune system, and emotional resilience to life's slings and arrows'. Modern neurobiological research supports that breastfeeding past infancy is healthy and normal, and fortunately this has more recently been reected in the policy and position statements of various professional associations.

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Trust the nursing baby Midwives and mothers mostly accept the natural unfolding of other milestones like readiness to sit, crawl, walk and talk – and they can similarly relax and trust the need to breastfeed until the child is ready to stop. Many mothers start out their breastfeeding journey already worrying about how and when they will stop – no doubt due to reigning non-physiological breastfeeding paradigms. So often a health worker's question 'Are you still breastfeeding?' (whatever Baby's age) suggests to the mother that continued nursing is not only unusual, but possibly wrong! With natural term nursing in mind, it must be remembered that in 1986, the World Health Assembly cautioned that so-called 'follow-on milks' are also replacement feeds for a breastfed baby, and are unnecessary. Introducing these derails natural breastfeeding.

Trust breast milk The nutritional and immunological value of breast milk continues way beyond six months! In fact, some immune factors in breast milk are present in greater amounts in the second year of life (when the child is more likely to be exposed to infections) than in the rst. Growth factors in breast milk help the immune system to mature, and help the brain, gut, and other organs to develop and mature. According to Dr Kathryn Dewey, in the second year of life 448ml of breast milk provides:

29% of energy requirements 43% of protein requirements 36 % of calcium requirements 75% of vitamin A requirements 94% of vitamin B12 requirements 60% of vitamin C requirements

The truth about weaning and complementary feeding Current weaning advice often results in mothers tipping the balance too quickly away from breast milk and on to other foods. Breastfeeding cannot be 'sustained for two years and beyond' (WHO recommendation) if from six months onwards the mother replaces breastfeeds with other foods; this leads to a reduced breast milk supply and loss of interest by the baby. Other foods are supposed to be in addition to breast milk, not instead of breast milk in the second six months of life. Many mothers also report how their baby 'weaned himself' before a year. However, this was probably mother-led weaning: they had likely given their babies solids before breast milk instead of afterwards; or three big meals per day plus snacks in between; and/or tried to cut back on the number of breastfeeds (often on the advice of health professionals).

Timing tyranny The 'tyranny of the clock' interferes with early breastfeeding rhythms, overriding the ability of mothers to read and respond to their babies' feeding cues. The 'tyranny of the calendar' has done the same, causing the premature and articial ending of a natural, biologically expected relationship. Even the terms 'extended' or 'sustained' breastfeeding suggest that this involves going beyond what is 'normal'; that nursing after six months (or a year, or two years) is somehow superuous. 'Nursing to natural term' sounds more like a consensual behaviour, and health professionals can be part of restoring this practice for the benet of mothers and children.

Continued on page 26

25


Nursing advice needs to be honest and given with mother-love. Sister Lilian Helping mothers to breastfeed to natural term

Here are six measures to guide health professionals with assisting mothers to get closer to the WHO recommended 'two years and beyond', and preferably to allow natural term breastfeeding to unfold: 1. See it as an investment, rather than as a sacrice Explain to the mother that the longer duration of breastfeeding will bring long-term benets to her child and herself. 2. Share a broader perspective from other countries Many mothers all over the world have nursed their children for years rather than just weeks or months. 3. Advocate breast milk itself as the perfect weaning food Breast milk should be regarded as part of a 'real', 'normal' diet. It makes sense to ensure the availability of this resource right through the weaning period until the child can be fully dependent on – and can absorb all the necessary nutrients from – other foods. 4. Share the concept that children need to ease into independence Breastfeeding to natural term meets the need for healthy attachment and security, ultimately leading to appropriate and robust independence and self-reliance. 5. Support the mother by acknowledging her emotions There may be times when she feels ambivalent, doubtful, different or isolated while breastfeeding a toddler. If she faces criticism and judgement in her community, you can build her self-esteem and condence about the wise choice she has made, and support her instinct to cherish this relationship. 6. Reinforce how it is a wonderful 'mothering tool' when a child is sick or injured As Dr Jack Newman witnessed in the Paediatric Emergency Department: 'The mother comforts the sick child with breastfeeding, and the child comforts the mother by breastfeeding.' Breast milk has a calming or sedative effect on a child, contains endorphins, is a natural electrolyte solution, and may be the only food or liquid the child can tolerate. See references on page 33

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Dimensions

art Inner healing & power through

Stacey 's story As an artist and owner of Dilly Dolly – a small Johannesburg studio selling whimsical watercolour paintings and prints – Stacey Smit is no stranger to art. And yet, she says, this piece was 'the rst painting I've done for myself in many years'. Like many expectant moms, Stacey had taken photographs of her changing body throughout her pregnancy, but she wanted to 'document something that was less obvious, something that embodied this major transformation'. The piece began with simple curved lines, representing her growing belly. Stacey explains how the image became a metaphor for the many layers of (often unexpected) change she experienced during pregnancy, birth and motherhood. 'Words were not enough to communicate the journey I went through. The painting enabled me to see the transformation of a traumatic event into something positive and powerful – my own metamorphosis and rite of passage. Having an image to embody that was incredibly cathartic,' says Stacey. See more of Stacey's work at www.dillydolly.co.za.

Sensitive Midwifery Magazine writer Kelly Norwood-Young explores how art can allow parents to access and cope with their authentic feelings about pregnancy and birth. power and therapeutic value of creative expression has T he been acknowledged throughout history and across cultures,

but it was during the last century that the work of Carl Jung allowed art therapy to develop as a psychotherapeutic approach. Simply, Jung was convinced that we have the innate ability to overcome our fears and heal ourselves from within, by consulting with our unconscious minds. Art is a powerful way to make the unconscious conscious. During a time of immense change, art can allow a pregnant woman or new mother to delve into her deeper feelings about pregnancy, birth, and motherhood, providing a deeper sense of self and even healing from traumatic experiences as she brings forth images from her inner world.

From expression to empowerment

For doula Rosalia Pihlajasaari, art is an integral part of the antenatal preparation classes and discussion groups she runs for expectant parents. Rosalia began incorporating art into her work with clients in 2005, after attending Birthing from Within training with author and midwife Pam England in New Mexico, and has found the practice to be enormously helpful for parents. Rosalia wants midwives and doulas to know that, 'You don't need to be an art therapist for this to work. Guide a client through this process, allowing them to interpret their own work, so they can process their own inner feelings, concerns, or wishes. Use openended questions to stimulate the pregnant woman or couple to dig deeper for the answers only they can know. Listen deeply to what the client says, and be non-judgemental. They are leading the way to their own awakening and knowing; the mentor is merely holding the space for them to navigate through the unknown waters.'

Inspired by the metamorphosis I experienced during my rst pregnancy and birth, I used my growing tummy pics as reference to draw gentle curves on paper which I then lled with subtle marks of change. Stacey

Continued on page 29 28

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Dimensions

Creating connection with art

Antenatal art from the Healthy Mom and Baby Clinic in Jeffreys Bay

One of Rosalia's favourite art activities is what she calls the 'Womb with a View': A pregnant mother who's having trouble connecting with her baby draws or paints what she thinks her unborn baby would see if he could peer out of the womb. This exercise typically reveals what the mother's current focus or preoccupation is, and as she attempts to look through her baby's eyes, this process also gives her an opportunity to imagine her baby as a sentient being. Rosalia also asks her clients to visualise and express their fears about birth through art. Once these fears have been brought to the forefront, Rosalia runs through the second part of the exercise; that is, asking expectant mothers to visualise themselves in the same situation, but to shift their perspective – to now see themselves as coping with the feared event or experience. Rosalia explains, ‘It's not about eliminating the fear, but rather, it's about coping. Once women see themselves as coping, there is a switch in the brain.' If a woman's fears about birth do come true – if she needs an episiotomy or a C-section, for example – she will remember this visualisation and know she is strong enough to handle it. Rosalia then asks her clients to 'take a snapshot' of that unwished-for event, saying to them, 'When you're ready, pick up a colour – any colour – and just start.' Of course, the emotions that are evoked during pregnancy and birth are complex, and different for every woman. Art can be a signicant tool for expressing positive experiences too – for accessing inner joy, excitement, peace, and power. Indeed, Rosalia has encouraged clients to use clay to make a 'power sculpture' – something to focus on during labour that reminds them of their innate strength, as well as all the positive energy they've been gathering in their pregnancy. Sister Lilian comments, 'While art as therapy implies that it is mostly used to process traumatic experiences, this medium is extremely benecial to prevent anxiety. In the maternity setting, it can help women or couples give expression to, and face their fears. This empowers them to overcome their anxiety and be proactive in claiming their right to the overwhelmingly positive experience most pregnancies and births can and should be.’

Crystal is looking forward to using the birthing ball this time, and focusing on her breathing during contractions.

After the art While the value of this type of art lies in the process of making it, there are several ways moms can continue to nd meaning in what they've created. Doula Theoni Papoutsis suggests: Take the art to the birth: An artwork that reminds them of their inner strength can be particularly empowering and helpful to moms in labour. Store the art as a keepsake for the child: Artwork that expresses inner excitement or anticipation could make a beautiful gift when the child is old enough. Burn or destroy the art: This can be especially benecial as part of the process of releasing fears and worries depicted in the art.

Shaunique is very excited about her rst baby, even though she knows the pain will probably make her cry.

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Birth art is for everyone Doula Theoni Papoutsis also uses art in her work. When suggesting the process to pregnant clients, as a way for them to explore their inner feelings, Theoni sometimes, not unexpectedly, meets hesitation. For many, art is something last done at school in an environment where not only were they taught to make art 'pretty', but they were evaluated based on what they produced. As Theoni explains, 'Those who are reluctant at rst have often been told at some point in their childhoods that they weren't good enough.' For these self-conscious clients, Theoni emphasises that this process is not about creating a pretty picture: 'It's about expression. Start, and the rest will ow.' For many women, this is a signicant rst step to understanding birth. Rosalia echoes this, noting that 'it's not as much about what you're doing; it's about how you're confronting what is happening to you. Art lends itself very well to that.' Both Rosalia and Theoni emphasise how important it is that midwives engage in their own creative practice and process work. A midwife who has experienced the benets of art in her own life will be better able to guide clients.

From the profound to the practical There's no doubt that art is a process of meaning-making that has the potential to be both immensely personal and incredibly profound. Midwives can adapt artistic activities to suit the environment and the client's needs: Antenatal classes and workshops: The scope for integrating birth art into any birth processing class is huge! Private practice: Instead of talking through a mom's fears, midwives could guide them through the art process for 15–20 minutes, and it would have a deeper, more lasting effect, suggests Rosalia. Public sector: Sister Lilian notes, 'While seemingly more challenging, moms in antenatal clinics could doodle their feelings and thoughts, as part of what they do while they wait to be seen.’ Whether parents use a wide range of materials or stick to something simple like pencil or paint, midwives and moms must remember that the art process is more important than the medium used. As art therapist Judy Rominger, interviewed by Pam England, says in Birthing from Within, 'One image may want something gooey like ngerpaint, another something dry and soft like pastels, or one may call for something smooth and round like a lump of clay. So trust your intuition – whatever feels right for your art is right.' England, P and Horowitz, R, Birthing from Within, Partera Press, 1998 Malchiodi, C, 'Cool Art Therapy Intervention #2: Active Imagination', Psychology Today, 30 September 2010. Accessed at: https://www.psychologytoday.com/blog/arts-andhealth/201009/cool-art-therapy-intervention-2-active-imagination Swan-Foster, N, 'Images of Pregnant Women: Art Therapy as a Tool for Transformation', The Arts in Psychotherapy, 1989, 16, 283–292 Swan-Foster, N, 'Art Therapy: Pregnancy and Postpartum'. Accessed at: http://www.swanfoster.com/art-therapy/pregnancy-and-postpartum

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The rise of freebirthing Freebirthing (i.e. giving birth unassisted, without any medical assistance) appears to be on the rise. Is it a reaction against a restrictive, directive medical system, or a result of women feeling empowered to birth their babies on their own terms – or both? While Sensitive Midwifery Magazine is not unequivocally opposed to this approach, we would advocate a compromise (e.g. a back-up midwife in another room). Of course, a supportive, 'silent' midwife would never leave a woman feeling the need to go it solo. Free Birth Society. Accessed at: https://www.freebirthsociety.com/

Uncensored birth images on Instagram In response to this censorship, doula Katie Vigos has launched an online petition(@empoweredbirthproject). As Vigos says, 'Instagram continues to categorize physiological birth with pornography, graphic violence, profanity, and other subject matter it deems too offensive for the public eye. Birth does not belong in the same category as any of these things. This pervasive attitude toward birth is counterproductive to our mission of normalizing birth and releasing it from shame, stigma, and social taboo.' To nd out more or sign the petition, visit: http://bit.ly/2EJLpkS

The rise of social media has opened up places for mothers and birth workers to share empowering stories and educational information about pregnancy, birth and the postpartum period. Recently, Instagram has become a preferred platform for the birth community, with more people turning to this photo-sharing app to share real-life images and experiences. Still, many of these helpful and inspiring posts have been met with controversy as Instagram has removed photos or shut down user accounts, based on the violation of its strict community guidelines.

Vigos, K, 'Allow uncensored birth images on Instagram'. Accessed at: https://www.change.org/p/nicole-jackson-colaco-allow-uncensored-birth-images-on-instagram

Flaxseed oil Also known as linseed oil, axseed oil is derived by crushing and extracting the natural oils from the seeds of the ax plant. While cold-pressed linseed oil is popular in Europe as a nutritional supplement and to avour some foods, it's also been known for its common but declining use as a wood varnish and treatment. In this form, it's prepared in a way that makes it more stable against oxidation, but unsuitable for human consumption. Nowadays, one generally refers to axseed oil when thinking of health and nutritional benets. Flaxseed oil is very rich in the omega-3 fatty acid ALA (alpha-linolenic acid), which is converted in the body to the essential omega-3 fatty acids EPA and DHA, albeit less efciently than the ALA from fatty sh sources. For those who prefer a plant-based diet, daily ingestion of 15ml of axseed oil can, however, go a long way to addressing omega-3 requirements. It's important to purchase axseed oil that is expertly extracted, decanted into dark glass bottles for light sensitivity, and to keep the oil refrigerated as it becomes rancid more easily than some other plant oils. Various animal and small human studies indicate that regular supplementing with axseed oil reduces skin irritations and itching, can alleviate both constipation and diarrhoea, helps improve heart and blood vessel health, and may reduce some cancer cell growth. Flaxseeds also have these health benets and both can be added to salads and smoothies, or taken in their raw form. Link, R, '6 Benets of Flaxseed Oil'. Accessed at: https://www.healthline.com/nutrition/axseed-oil-benets Wikipedia, 'Linseed Oil'. Accessed at: https://en.wikipedia.org/wiki/Linseed_oil

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JOHANNESBURG 8 & 9 May 2018 INDABA HOTEL, WILLIAM NICOL DRIVE, FOURWAYS

TUESDAY 8 MAY 2018

WEDNESDAY 9 MAY 2018

REGISTRATION 07:30 – 08:30 • OPENING 08:30 – 09:00

REGISTRATION 07:00 – 08:00 • OPENING 08:00 – 08:30

SESSION 1 • 09:00 – 10:45 Re-imagine the future – video Keynote address The integrative health model: Its place in holistic midwifery practice Whose rights matter most: Mother or Baby? Over to you Delegate presentation

SESSION 1 • 08:30 – 10:15 Move it like you do - video Keynote address Gender understanding and tolerance in midwifery care The multi-dimensional birth team Differentiating fetal stress from distress, and new partogram protocols Termination of pregnancy: An ethical dilemma or not?

SESSION 2 • 11:30 – 13:15 Keynote address Revealed: The truth about exclusive breastfeeding, and the many implications of mixed feeding In discussion session Learning from key birth and breastfeeding case studies Birth breathing and the art of silence

SESSION 2 • 11:00 – 13:00 Keynote address Energy medicine: Placebo response, spontaneous remission and mind over matter Over to you Delegate presentation In discussion session Mothers' messages to midwives

SESSION 3 • 14:15 – 16:15 Keynote address Emotional system empowerment for midwives and mothers Gestational diabetes in perspective In discussion session Ensuring midwifery recognition, well-being and leadership

SESSION 3 • 14:00 – 16:00 The accoucheur angle Making a difference with BANC Plus Keynote address Repairing C-section and premature birth harm In discussion session How to attain 2030 goals by 2020

DURBAN • 14 JUNE 2018 COASTLANDS, MUSGRAVE

PORT ELIZABETH • 6 SEPTEMBER 2018 RADISSON BLU HOTEL, SUMMERSTRAND

CAPE TOWN • 27 SEPTEMBER 2018 RIVER CLUB, OBSERVATORY

REGISTRATION 07:00 – 08:00 • OPENING 08:00 – 08:30 SESSION 1 • 08:30 – 10:30 Re-imagine the future – video Keynote address Ensuring midwifery recognition, well-being and leadership Making a difference with BANC Plus In discussion session Mothers' messages to midwives SESSION 2 • 11:00 – 13:15 Whose rights matter most: Mother or Baby? Gestational diabetes in perspective Keynote address Revealed: The truth about exclusive breastfeeding, and the many implications of mixed feeding In discussion session Learning from key birth and breastfeeding case studies SESSION 3 • 14:15 – 16:15 Examining new partogram protocols How to attain 2030 goals by 2020 Over to you Delegate presentation Birth breathing and the art of silence Keynote address Repairing C-section and premature birth harm

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KEY RESEARCH REFERENCES IN ISSUE 39

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Facing your antepartum haemorrhage fears – page 8 Buchmann, EJ, 'Antepartum haemorhage' in Cronje, HS and Grobler, CJF (eds), Obstetrics in Southern Africa (2nd edi on), Van Schaik Publishers, 2009 Royal College of Obstetricians and Gynaecologists, 'Antepartum Haemorrhage', Green-top Guideline, November 2011, 63. Accessed at: h ps://sydneynorthhealthnetwork.org.au/wp content/uploads/2016/03/gtg63_05122011aph.pdf Wansink, SK and Vijay, N, 'Antepartum Haemorrhage: Causes & its effects on mother and child: an evalua on', Obstetrics & Gynecology Interna onal Journal, 2015, 3(1): ts/files/2016-12-22%20InterimNICDRecommdtnsCAuris.pdf Adop on and birth mothers – page 12 Aloi, JA, 'Nursing the disenfranchised: Women who have relinquished an infant for adop on', Journal of Psychiatric and Mental Health Nursing, 2009, 16 Brodzinsky, A, 'Surrendering an infant for adop on: The birthmother experience' in Brodzinsky, D and Schechter, M (eds), The Psychology of Adop on, Oxford University Press, 1990 Carr, MJ, 'Birthmothers and subsequent children: The role of personality traits and a achment history', Journal of Social Distress and the Homeless, 2000, 9 Chris an CL et al, 'Grief resolu on of birthmothers in confiden al, me-limited mediated, ongoing mediated, and fully disclosed adop ons', Adop on Quarterly, 1997, 1(2) Cushman, LF et al, 'Openness in adop on: Experiences and social psychological outcomes among birth mothers', Marriage and Family Review, 1997, 25 Feldman, P, Social Support During Pregnancy can Affect Fetal Growth and Birth Weight, Center for the Advancement of Health, 2000 Menon, JA et al, 'Percep on of care in Zambian women a ending community antenatal clinics', Educa onal Research, 2010, 1(9) Time to be kind – page 15 Fowers, B, 'What Makes a Person Kind?', 25 March 2016. Accessed at: h ps://www.psychologytoday.com/blog/ques ons-character/201603/ what-makes-person-kind Nursing to natural term – page 24 Bumgarner, NJ, Mothering Your Nursing Toddler, LLLI, 1982 Chelton, A, 'Words Ma er: Natural-Term Breas eeding', 12 October 2012. Accessed at: h ps://hearthsidematernityservices.com/.../words-ma er-natural-term breas eeding/ De wyler, KA, 'Full-term Breas eeding', AIMS Journal, 2013, 25(3). Accessed at: h ps://www.aims.org.uk/Journal/Vol25No3/fullTermBreas eeding.htm Dewey, KG, 'Nutri on, Growth, and Complementary Feeding of the Breas ed Infant', Pediatric Clinics of North American, February 2001, 48(1) Greiner, T, 'The Concept of Weaning: Defini ons and Their Implica ons', Journal of Human Lacta on, June 1996 King, BJ, 'What's Right About A 6-Year-Old Who Breast-Feeds', Cosmos & Culture, on NPR (Na onal Public Radio), 15 January 2015 Lawrence, R, Breas eeding: a Guide for the Medical Profession, 1994 Nagle, M, 'Breas eeding an older child – why on earth?', LLLI Online Conference, 2017 Orlinsky, K, 'Breas eeding: Comfort versus Nutri on', 1989. Reprinted in h p://www.naturalchild.org/guest/kathryn_orlinsky.html Stuart-Macadam, P and De wyler, KA (eds), Breas eeding – Biocultural Perspec ves, 1995

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Last word When the tool becomes the master We asked Michel Odent – obstetrician, and birth and human nature researcher – to share some key concepts from his latest book The Birth of Homo, the Marine Chimpanzee

H

is objective in this book, explains Michel Odent, 'was to illustrate through an example the current cultural blindness related to ultra-specialisation. For each of the countless particularities of our own genus Homo in the framework of mammal species, even the most mysterious, specialised scientists can offer multiple plausible interpretations in terms of evolutionary advantages and adaptation to different environments. 'Meanwhile, there is no interest in a possible unifying theoretical framework. However, we have at our disposal such a unifying framework, based on a simple rule: when a trait is mysterious, and apparently specic to humans, we must look at what we have in common with mammals adapted to the sea.'

The sense of smell of human beings is mysteriously weak. It is the same among whales. When whales separated from hoofed mammals about 60 million years ago and migrated to water, their sense of smell nearly disappeared. Body temperature control through the loss of sweat is not a costly mechanism if we think of the human being as a primate adapted to environments where water and minerals are available without restriction. A low larynx, which gives us the ability to breathe through our nose or our mouth, is an anatomical particularity shared with sea lions and dugongs. A prominent nose is a feature shared with the proboscis, a primate who lives in the coastal wetlands and is an excellent distance swimmer. The human vagina, like that of sea mammals, is long and oblique, and is protected by a hymen. One of the most common abnormalities (or particularities) among humans is a webbing between the second and the third toe. When a congenital abnormality is an addition, it usually means that the feature was there for a reason during the evolutionary process. A narrowing of the thoracic aorta (coarctation of the aorta) is common among humans and seals. Menopause, and prolonged life after reproduction, is a feature shared by humans, killer whales and short-nned pilot whales. Concludes Dr Odent: 'The practical implications of this new understanding of human nature are enormous, particularly for those involved in pregnancy and childbirth.'

The sea connection Dr Odent has previously written about the importance of including seafood in an expectant mother's diet, explaining that iodine is the most common nutritional deciency among humans, except among those who have access to the sea food chain. Now, he gives Sensitive Midwifery Magazine readers examples of some human traits which are shared with sea mammals: The huge development of the brain: mammals adapted to the sea generally have a higher 'encephalisation quotient' than their cousins on land. An enzymatic system that is not very effective at making a molecule of fatty acid (DHA) which is essential to feed the brain. This molecule is abundant and pre-formed in the sea food chain. Nakedness and a layer of fat under the skin are traits shared with sea mammals. The skin of human newborn babies is covered with vernix caseosa (literally, cheesy varnish), like the skin of newborn seals. Human mothers do not eat the placenta; neither do sea mammals.

Order this book from any of these three online stores: https://www.exclusivebooks.co.za/product/9781780664453 https://www.takealot.com/the-birth-of-homo-the-marinechimpanzee/PLID44951738 https://www.amazon.co.uk/Birth-Homo-Marine-Chimpanzee-Becomes/dp/1780664451

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eSMM Mar 2018 issue 39  

An interesting, inspiring, challenging magazine for ALL midwives, doulas and other maternity professionals

eSMM Mar 2018 issue 39  

An interesting, inspiring, challenging magazine for ALL midwives, doulas and other maternity professionals

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