Continuity that crosses cultures by Global Doula Lina Duncan

Lina lived and worked as a midwife in Asia from 1998-2016 She was in the Philippines 1998-2002 and in India 2007-2016 Lina worked in local (Philippines) and international communities, especially in India and provided perinatal care for families through a private limited company and networking with local communities through relationship. She now works as a doula in London and her website is globaldoula.com

#continuitymatters

When I was a student, and later a supervisor midwife in the Philippines we had to think on our feet and be able to act fast, be calm, compassionate and also make sure the women were in the centre of the decisions surrounding their care.

The clinics I worked in as a volunteer were community based and simple buildings that were welcoming and free to those who could not afford to pay the small costs that were entailed. Women who accessed these clinics were women that may otherwise have birthed at home, which would be fine for some but dangerous for others. I support and love to attend homebirth but in a system that does not encourage knowledgeable and safe birthing services outside of hospital it did put women and their babies at risk. They either free-birthed or birthed with women called “hilots” who were indigenous midwives. Some hilots were very skilled and some kind of winged it. I can understand why a woman would want to stay in her home with a local hilot rather than risk her dignity and debt in a crowded and abusive hospital.

The only alternative for the poor, to go to over-crowded hospitals and receive conveyor-belt care where all women were treated the same. This was 1998-2202. All women had to buy IV fluids, cannulas, syntocinon, suturing materials etc. A long list of medicines were required to be purchased before admission to hospital would be permitted. It was also mandatory for every woman to have a “buntay” which means a companion 24/7 should she need any basic care or any other medications.

The financial component itself was enough to deter many women from entering the hospital. These were women who could barely feed their own children, let alone their pregnant self.

The other component to avoiding hospital care was the overcrowding, dirty, and abusive circumstances that existed in the busy city hospitals. I witnessed women sharing beds in labour, being stripped naked, shouted at, slapped and given fundal pressure with force that was frightening. Consent was not a thing. Episiotomies were the norm. Bear in mind that when we needed to transfer women into hospital (with their consent) we tried our best to remain with them so that they experienced continuity of care. The Cochrane says that women who feel satisfied with their births are supported throughout, female companions are one of these factors.

I hope no one reading this has seen the technique that I saw a hundred times. It’s one of those things that happens in institutions where you learn on the job and don’t experience any other way. It’s the way things were done. It wasn’t OK and I sincerely hope that this is no longer practiced but I fear it is as I saw similar in government hospitals in India when supporting illiterate women as a doula, we had continuity by relationship. Fear-based-birthing, is what I’ll call it. The women were told that their babies were dying, heart rate slowing etc and they were made to lie flat on their backs with feet in stirrups, shouted at to push as long as and as hard as they could to get their baby out. This alongside being mostly naked and with someone standing on a stool and pushing down hard on the top of their uterus to expel the baby. It was horrifying. A nightmare. I used to stand by the woman’s side and hold her hand and pray. I had to communicate with her with my eyes or whispers at the risk of being asked to leave.  It was so abusive and distressing and to see women that I had come to know and care about, treated like this, was disturbing. Every time I wondered what harm was being done to either the mother or the baby. I was actually surprised that as an “observer” and an “outsider” to the hospital that the abuse carried on regardless of my presence. I suppose it was that much ingrained?

This is why our clinics were created, so that women could choose to birth in a venue where there was dignity, respect and compassion. I’ll call this love-based-birthing (and credit Red Miller for influence of the words as it’s the title of her book #fromfeartolove and her social media etc.)

Lina word cloud

So now comes the good part. I had to set the scene so that the rest makes sense.

Continuity. Safe. Same faces. Vulnerable women. Fear to love. Poverty. Malnourished. Domestic violence. Substance abuse. Hunger. Sexual abuse. Illness. Death.

Many women who walked through our doors had experienced some, or all of the above. Some of them disclosed. Others didn’t. We treated them all as any woman deserved, with dignity and compassion. We looked into their eyes. We told them our names. We listened. We waited. We drew curtains. We used cover sheets. We tried to do everything with kindness. Isn’t this how women should be treated globally, in every culture?

Sometimes there was over 100 women in one day to be seen by just a few of us for an antenatal. It didn’t give us much time to spend with each woman. One of my supervisors who did the screening in the main room, used to write my name in pencil on the folder of women who stood out to benefit from continuity. They were generally under 18 or having their 5th baby or more. Maybe they had a health vulnerability or a social one or maybe it was her instinct but it always made me smile and pay a little bit more attention. I would change the pencil to pen as I decided to take that woman as a continuity of care. I sometimes had more than five per month and that was on top of normal shifts. They would often present in labour at the end of my 24 hours birth shift! If they didn’t arrive in active labour or transition I would grab some time to shower upstairs and then come down and be with them in labour. I kept a journal and pictures of every birth I was the primary midwife or assist midwife for, the dates of her antenatals and how many I had done, DOB, weight of baby, birth position, EBL and any other useful statistics I could think of. I still have those books and fond memories of my midwifery days in Cebu City and Davao City in the Philippines.

Lina Children

Some women became a postnatal continuity through circumstance. I can think of two women immediately, one was only 16 and one was in her thirties. Both had no antenatal care and both birthed on my shift. One baby had a distinct heart murmur on day 3 that I detected in her postnatal visit and followed up with them at a paediatric cardiologist. The other baby was born with meningoencephalocele. The baby with a heart condition was put on medications and she was adored by her 4 siblings, parents, neighbours and midwives. In my spare time I made many visits to their home with another midwife and sometimes we went along with them to the hospital visits too. Sadly she died at 4 months. The family called me from the government hospital where we had been visiting them and I was able to leave my shift and go straight there. I haven’t forgotten that day, the sounds of grief and the sadness of her loss.

The little boy with meningoencephalocele was much loved by his mum and lola (nana) for four years and I was also notified of his death via the clinic in that city as I had moved back to the previous city.

Lina stilt houses

One of the women I used to visit at home concerned me a great deal. I knew she was a past and current survivor of domestic violence. I used to sit in her little wooden shack on stilts that rocked with the waves (pictured above), along with a colleague midwife. The woman was feisty and funny. She had lost most of her teeth and was malnourished but no other symptoms of chronic illness. She had 4 other children who were equally playful and cheeky. I had to leave the island for a trip and was gutted that I might miss her birth but anyway she had continuity with my friend also. On my return nobody had seen her and I wondered if she had birthed alone at home. But no, she was 42+ weeks pregnant and shy to come back to us at the clinic. I persuaded one of the cooks to go see her as I was on shift and it turned out she was in labour and on her way to us. I will never forget spending hours in silence with her as she did whatever was needed to birth her baby and then crashed out in a deep sleep with her little boy, skin to skin and nursing on her chest whilst I did her postpartum checks.  I can’t explain the compassion and love I shared in her friendship. She was not a noticeable woman but she was special. I always wanted to give my best to everyone but I think she may have got some extra attention. She deserved it. ❤

I was deeply saddened when my friends contacted me, having moved islands, to tell me that she had undiagnosed Tuberculosis in her bones and it was too far along to treat.

I did go to too many funerals in Asia.

I noticed that many of the younger women I supported in continuity of care let their guards down over time and were very open to suggestions such as laboring and birthing in whatever upright position felt best to them. I witnessed them letting go and instinctually birthing as their bodies led them too. It was sweet to take a back seat, sit in the corner and see their partner or family members do most of the hands-on support during labour and birth. This was not a cultural norm as due to the busy government hospitals, men were not allowed to enter the labour or “delivery” ward. Other men were fearful to give support or be in the room or they were at home looking after the other kids, and I supported to many women continuously throughout their labour and birth as well as the antenatal and postnatal care. We were diligent in our recording but it wasn’t something we had to leave the room for and we never had to leave a woman alone.

In the four years I lived and worked in the clinics we experimented with different models of care and we did the case-loading style for the last 2 years of my time there. This went something like this:

  • Small teams of 3-5 midwives including students, locals and foreigners.
  • An assigned 12 hour antenatal day for your team (we were Monday team)
  • One day shift
  • One night shift
  • 24/7 on call

This meant that our team always worked together on the Monday and the women in our team got to know us and vice versa. We did all their antenatal care. We could follow up if they didn’t attend by doing home visits. We could encourage community links with women that needed extra support from neighbours. When they presented at the clinic in labour someone from our team would go over and meet them and be with them in labour. If they chose to stay at clinic then at least two of the team was there to support that birth. We also did all their postnatal care, scheduling visits when we would be on shift at the clinic.

We also saw many adverse situations, rare birth defects, still births and some perinatal death. As we already had relationship with the families we could support them in ways that were caring and healing. We gave them the choice as per where they wanted to birth and usually they chose to stay with us at the clinic because the hospital was pretty barbaric with stillbirth, blaming the woman and not giving her a chance to grieve. She would be placed straight into the postnatal ward with two other women and two other live babies to share a bed with. How insensitive.

When women and their families faced the terrible sadness and reality of stillbirth and chose to stay at the clinic, we were able to support their labour and birth continuously with choices and options for making memories with their baby and we even did some funeral ceremonies for some. Of course this was heartbreaking, but it was also a natural continuity of care. Some of those women are still friends today.

Although the conditions in which these clinics were based may have appeared dangerous and hopeless, they were far from that. These people were survivors and strong. Yes, many of them were victims to circumstances carried through generations but they didn’t choose to live and reproduce in that environment. The taxi drivers used to refuse to drop us “inside” the area at the beginning. The place had a bad reputation. I can say that I was never afraid though. We often ran (I was the fastest in my team J) to the clinic from our big community house, ran through the centre of the community, past the pig slaughter house where the squeal of pigs were heard all night, past dodgy looking men that you didn’t want to look in their eyes, past the streets that were never totally empty and dodging the poo of various animals on the street path. Of course it was often a night dash because babies generally made their journeys earth-side by the light of the moon.

Lina street

It was so much more rewarding to work in the model of continuity, the recognition, the smile of friendship, even in the throws of labour. I could probably write a book of stories on this because I only just started and have hundreds more stories to tell on the benefits of continuity, especially for the vulnerable in our societies, but of course not only, continuity for all has always been my motto and always will be.

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One thought on “Continuity that crosses cultures by Global Doula Lina Duncan

  1. francoisebarbira says:

    your blog is important, beautiful, relevant, thank you! We are preparing an international conference
    in London on continuity in maternity care across cultures (late September 2019), would you be able
    to present? This is part of our Womb to World conference series, my name is Francoise I am the founder of Birthlight. Could you send me an email at francoise@birthlight.com, thanks, I would like to be in touch with you.

    Like

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