There are so many great items available online. This can be the ideal time to add to your library, birth bag or teaching supplies. How about considering the following?

Pelvis & Doll

One of the most useful items if you are teaching childbirth classes is a pelvis and doll. Several different companies provide them.

National Childbirth Trust (UK): http://www.nctms.co.uk/prodlist.asp?sc=pelvis&a=srchw

Birth International (Australia & UK): http://www.birthinternational.com/product/model/index.html

BirthSource (USA): http://www.birthsource.com/scripts/prodList.asp?idCategory=43

Cascade Healthcare (USA): http://www.1cascade.com/ProductInfo.aspx?productid=1195

Charts

One of the best set of charts that we have come across are a series of photographs taken of various stages of labor and birth. These pictures show an excellent variety of different types of birth, interventions and natural births, and many different cultural groups. The pictures are produced by Lina Clerke, an Australian midwife and doula, and are available through her website at: http://www.wonderfulbirth.com/default.asp?url=2955&Type=3

Anatomy and Physiology Charts

Birth International, UK & Australia: http://www.birthinternational.com/product/chart/ch005.html

Birthsource, USA: http://www.birthsource.com/Scripts/prodView.asp?idproduct=123

Giving Birth Charts

OUR FAVORITE: National Childbirth Trust, UK: http://www.nctms.co.uk/prodshow.asp?id=138&cat=0&scat=0&parent=

Birth International, UK & Australia: http://www.birthinternational.com/product/chart/ch023.html

Poster of Positions for an Active Birth

National Childbirth Trust, UK: http://www.nctms.co.uk/prodshow.asp?id=588&cat=0&scat=0&parent=

Birth International, UK & Australia: http://www.birthinternational.com/product/chart/ch002.html

Cards and tear off pads of Positions for an Active Birth

National Childbirth Trust, UK: http://www.nctms.co.uk/prodshow.asp?id=614&cat=0&scat=0&parent=

Books

You could simply choose a gift voucher from Amazon, allowing you to choose any book you like. Or, you could do a “wish list” and include the books you have wanted to read, or have chosen for your training. Amazon have a facility where you can create your own wish list and then email the link to friends and family.

Training

If you have been putting off training because of the cost now might be the perfect time to ask for your training as a gift – either as a present from one person or having several people contribute towards it. Some training organizations offer gift vouchers so part of the training cost can be purchased. Check out Childbirth International’s gift voucher option for more information.

This article highlights many of the myths that surround VBAC and the importance of the beliefs of the caregiver in determining whether or not a VBAC will be even attempted, let alone successful. One of the authors refers to the Landon et al study (2004) which provides us with the best information on the safety of VBAC versus a repeat cesarean. This study contradicts the commonly held belief that cesarean is safer than VBAC for either mothers or their baby’s.

The family physician offers a number of reasons to explain the increasing cesarean rate which is a global phenomenon including a feto-centric perspective held by many caregivers where they feel they are responsible for being the advocate of the unborn child, despite the increased risks to the mother of a surgical birth. At the end of his discussion the physician confesses to having previously told one of the women in the story that a VBAC was unlikely to be successful and has since recognised that as a careprovider caution should be exercised when giving advice because of the huge impact a doctor’s words can have on a woman.

Overall this is an excellent article – one that is worth including in the information available to the parents you work with who may be considering VBAC but have had family or caregivers voice concerns over its safety.

The article is called: Roundtable Discussion: “No One Can Condemn You to a C-Section!”

Authors: Feldman, P., Cymbalist, R.,  Vedam, S., & Kotaska A

Birth, vol. 37, iss. 3, pp. 245-251

Hmong women traditionally give birth at home, with their mother and mother-in-law present. They birth in upright positions, often standing or squatting in the doorway of the bedroom. An older village woman who has experience of childbirth may also assist a laboring mother. She is not viewed as a traditional midwife and the Hmong language has no word to describe her role. Her husband may also be present and helps with cutting the umbilical cord and washing the baby after the birth.

The Hmong believe that the head is where the soul is housed, and contact with a baby’s head is minimized. The baby’s head should not be in contact with the ground.

The baby’s placenta is highly respected, and is buried inside the family home. It is believed that at death, a person returns to their place of birth and collects their placenta, referred to as their “black jacket”. They then carry this into the afterlife as a mark of humility. When a Hmong woman is living in a high rise apartment and birthing in a hospital it can cause the family great distress as they do not know what will happen to the baby’s placenta.

Hmong women believe that nobody other than their husband should see their genitals, and are particularly uncomfortable with vaginal examinations. This often prevents Hmong women in Western countries from seeking early prenatal care as they are worried about having to endure vaginal examinations as a routine part of that care.

Hmong women are particularly concerned about cesarean birth. They believe that each person has three souls called the “plig”. Provided these three souls are within the body, the person is healthy. A soul may temporarily leave a body but usually finds its way back with no incident. However, when unconscious, a soul may leave the body and not return. this results in illness and requires a shaman to perform a special ceremony where he calls the soul to return. In order to lock the three souls into the body of a newborn, a silver necklace is placed around their neck, preferably before the cord is cut. If the family cannot afford silver, a white cord may be used instead.

Baby’s born in the caul (inside the amniotic sac) are thought to be particularly lucky as this is an indication that they lived a previous life as a king and the child is now born wearing the cloth from that previous life. The Hmong believe the child will live a life of prosperity and good health. If a child is born in the caul, the caul is dried and kept, and passed on to the child when they are older. The “cloth” will then be given back to the person when they die to ensure they are reborn again to live a prosperous life.

Like many Asian cultures, the Hmong avoid giving too much praise to a child for fear of this attracting evil spirits and harming the child. They will often greet their child with comments about how ugly they are are in order to ensure the spirits awareness is not raised and their child will be protected.

Women in Hmong society practice a period of 30 days of confinement where they are seen as weak and vulnerable, needing special attention. They are not required to carry out any heavy work and will be kept warm and provided with special foods. They will not wash (with the exception of a sponge bath) during this time to prevent their hair from falling out or becoming chilled. They may use a steam bath where they sit beside a hot pot of water that has had special herbs added, and allow themselves to sweat to remove any impurities from their body. Generally their diet will be restricted to hot rice and chicken soup with herbs added, although they may also eat eggs, pork and fish. Hmong women in Western society may find their hospital stay difficult as they are not able to eat the food on the hospital menu and may have family bring in specially prepared food for them.

Three days after the birth a Hmong child is given his or her name. The father may also be given a new name to recognize his new status as a father.

Childbirth International and Cultural Diversity

We believe that with knowledge of different cultural groups, particularly in the field of pregnancy, childbirth and parenting, we can all learn from each other and eliminate intolerance and prejudice.

We seek to explore different birthing practices and beliefs from around the world, opening up our understanding and bringing the rest of the world a little closer.

Childbirth International courses explore cultural differences and different value systems, enabling students to become more aware of the rich variety of women and families that they will be working with.

Anke, great question! When you browse through the catalogs of the various educator supply organizations it can be tempting to want to buy all the charts, videos and equipment. However, the cost of these all add up and can make it seem impossible to ever get started.

The key is to choose a small number of items that are likely to be the most useful and use homemade tools everywhere else. The most useful item is a pelvis and doll. You will find that you use these again and again in your classes and having a model pelvis to look at and hold can make a real difference in clients understanding the importance of upright positions and the movement of the baby through the pelvis. You can purchase a pelvis from of a number of different companies who sell childbirth educator supplies, and sometimes can pick one up second hand through websites like Ebay. The cost of a new pelvis is around US$50-$75. Many of them come with dolls. However you can usually find a much cheaper doll from a toy store. Just make sure you take your pelvis with you when trying them out for size to ensure they move through the pelvis easily.

There are some amazing videos available now to show different aspects of pregnancy, birth and parenting. They do tend to be quite costly and it can be difficult to find ones that depict completely natural birth in an environment that is likely to be one your clients will choose. For example, it can be hard for a pregnant woman to relate to the video if it shows a woman giving birth unassisted at home when she has chosen a hospital birth with an obstetrician. Take care when choosing videos that are very explicit. For many first time parents seeing a full frontal shot of a baby emerging can make them uncomfortable and defeat the purpose of the video. Consider the reason why you want to show a video. If you are trying to show a variety of different births and how many choices are available to your clients, a series of short videos downloaded from You Tube may suffice. If you have Realplayer installed on your computer you can download the videos you watch on You Tube and show them in classes when you are offline.

Charts of pregnancy and birth can be helpful but are not really essential. Rather than using a chart to show dilation, you can use your own hands and head. Cup your hands over the top of your head and slowly move them down the side of head to show the cervix opening. Use your arms and hands to demonstrate the shape of the uterus. you can then bring your hands upwards and apart to demonstrate effacement and dilation. Some educators use a knitted uterus to show the same thing and there are many patterns online to teach you how to knit one yourself.

The third stage can be demonstrated by inflating a balloon and sticking a postage stamp to the side. As you slowly deflate the balloon the stamp will peel away in a similar way to the placenta peeling away from the side of the uterus.

You could try joining birth professionals groups in your local area, connecting with local midwives, or joining an email group for birth professionals. Often you will find someone who is moving out of this field and looking to sell all their visual aids at a low cost.

Ultimately, the most effective tool you have available to you is yourself. Newer childbirth educators may find that the visual aids are simply being used as something to hide behind. What you share with a group of pregnant couples, teaching them in an actively engaging way, is far more beneficial than all the visual aids in the world!

How does Childbirth International training address this?

As part of Childbirth International’s childbirth educator training program, we look at a number of different ways to teach sections of your course that are low or no cost. A teaching plan is provided for your free use and can be adapted in any way you like to suit your clients.

Each activity in this plan has been developed with consideration of active teaching skills and providing classes that are relaxed, fun and packed full of great information for expectant parents.

We provide resource lists of where you can purchase educational aids and also have an active student email list where you can get ideas on how to teach your classes on a budget and network with other birth professionals.

It is hardly news that when women are making birth choices their finances will factor into their decisions. What was surprising was that more women were choosing midwifery care and homebirths, options known to be lower cost than obstetric and hospital care. The downside is that birth professionals are finding it difficult to make a living and some are choosing to find alternative employment to make ends meet.

Economy affects birth choices

We asked respondents to tell us whether they had noticed changes in the past 6 months in terms of the choices women were making for their births. They identified several key areas that had changed:

• 51% of respondents said more women were planning midwifery care and/or homebirths
• 45% of respondents found the number of inquiries had decreased significantly in the last 6 months
• 42% noticed more women were asking for discounts
• 20% found that less women were choosing planned epidurals and/or cesareans
• 20% had noted an increase in the number of uninsured women they were working with
• 13% of respondents were having increased numbers of clients not paying their bills

Economic downturn reduces income

We found that many birth professionals were finding they were making significantly less money and this was causing some to have to contemplate moving into other jobs as they could no longer manage on their birth income. While many respondents stated that the income from their birth business was a minor source of family income, a staggering 77% wanted their income to become the main or a significant part of the family income.

In a previous survey carried out by Childbirth International, more than 50% of respondents said they would like to have further training in establishing and building their business. The issues they identified as being areas of concern included:

• increasing the number of clients
• help with business forms and sample contracts
• managing financial and legal aspects of a business
• website development and advertising
• making their business profitable
• contributing to a significant portion of the family finances

Many birth professionals have never run a small business prior to moving to this field of work. Being self-employed requires learning a host of new skills, including marketing, sales and financial management.

Childbirth International launched the Get More Clients! course to address these needs. Carrying out additional training to help develop new skills and increase knowledge can have a significant impact on your business. Imagine you are able to increase the number of clients you have by just 1-2 a month and you make a profit of $200 for each client. In a year you will have paid for the course 25 times over!

More information on Get More Clients!

How does Childbirth International training address this?

Childbirth International has a course that addresses all the concerns related to running a birth professional business. Written by birth professionals with experience in several successful birth businesses, the course is packed with tips, ideas and practical suggestions on growing and developing a birth related business. It can help you develop a new business, grow an existing one, or give you a boost if you feel you are not heading in the direction you wanted.

Western culture tends to view the placenta as a waste product to be disposed of after the birth. In many cultures though important ceremonies takes place involving the placenta.

It is common to find the placenta being buried in or near the child’s home, believing that the placenta binds a child to his or her ancestral beginnings. As we discovered in our last newsletter, the Hmong communities in Asia call the placenta the “black jacket” – a child’s finest clothing that will be carried with them after death. Balinese fathers are responsible for washing and preparing the placenta, and subsequently burying it by the front door of the family home. Maori’s of New Zealand also bury the placenta – the same word is used in the Maori language for placenta and land, “whenua”. The Sundanese bury the placenta under a window at the back of the family home.

Navajo parents bury the placenta and the umbilical cord in a place that represents their dreams for their child. Thai parents also bury the placenta. It is first salted to preserve it, then it is placed in an earthenware pot, before being buried on an auspicious day. The location is chosen depending on when the child is born, with a site chosen where a plant that represents the child’s year of birth is grown. For example, the coconut tree watches over the placentas of babies born in the year of the rat, the dragon or the rabbit, while the lotus protects babies born in the year of the tiger and dog.

Many cultures believe the placenta has its own spirit. Aymara and Quecha fathers from Bolivia wash and bury the placenta in a secret shady place to protect the mother and baby. The Ibo people of Ghana and Nigeria give the placenta a traditional burial as the twin of the child.

Traditional Turkish families believe that the way the placenta and umbilical cord are treated can influence the child’s future. The umbilical cord will be buried in a place that then determines the child’s characteristics as an adult. Burying the cord in the courtyard of a mosque ensures they will become devout, while throwing it into the water means the child will seek their destiny away from the family home. The placenta is believed to be a part of the child and, like the Ibo, it is wrapped and buried.

How does Childbirth International training address this?

We believe that with knowledge of different cultural groups, particularly in the field of pregnancy, childbirth and parenting, we can all learn from each other and eliminate intolerance and prejudice.

We seek to explore different birthing practices and beliefs from around the world, opening up our understanding and bringing the rest of the world a little closer.

Childbirth International courses explore cultural differences and different value systems, enabling students to become more aware of the rich variety of women and families that they will be working with.

This week we feature a newsletter produced by midwife extraordinaire Ibu Robin Lim who works tirelessly to provide care for families in Bali. A large part of her work is focused in Aceh (pronounced Ah-Chay) – an Indonesian province that has experienced years of fighting, and is now trying to pick up the pieces after being devastated by the 2004 tsunami.

Robin operates the only birthing center in South East Asia and provides free or low cost care to local families. She has kindly given us permission to include her March/April 2009 newsletter below. At the end of the newsletter you will find information on how you can help the amazing work that Robin and others are doing to help the women and children of Bali and Aceh.

Bali is a small island that mainly farms rice and supports itself with the tourist dollar. People in Bali mostly practice a form of Hinduism. The maternal mortality rate in Bali is 718 deaths per 100,000 births with nearly half these deaths being caused by postpartum hemorrhage, largely due to malnutrition. Aceh is on the island of Sumatra. There have been ongoing conflicts there for many years. The two main religions practiced are Islam and Christianity.

Bumi Sehat is entirely funded by donations and all work is carried out by volunteers. Robin told us that it is the small donors that make a huge difference and enable Bumi Sehat to continue operating. If you can help, please do, in any small way possible. Send your thoughts to Robin and her team who work in difficult conditions to make birth safe for families that have so little.

Bumi Sehat Aceh Field Report – March/April 2009
by Ibu Robin Lim

The people of Aceh wake to a huge pink sky, and they look toward the sea. The sea, that forever looking backward in history, has been the people’s source of sustenance. The sea they harvested giving them work and the poetry of food, it has been their art, their life.

They look at the calm sea today and they remember the day of betrayal, of salty tears, December 26^th 2004.  At just about 8 a.m. an earthquake measuring 9.3 on the Richter scale struck. It was a terrible earthquake, but the people of Aceh had long lived with the shaking of their Sumatran foundations.

Then the sea betrayed them, a Tsunami. Not one wave but many, growing bigger and blacker and filled with all the churned broken belongings of modern life. Roiling with police cars, sheets of metal and glass, hunks of cement, furniture, animals still trapped in their cages, people, people who were quickly becoming corpses, by the hundreds of thousands.

They look at the calm sea today and they remember the day of betrayal, of salty tears… Not one wave but many, growing bigger and blacker and filled with all the churned broken belongings of modern life.

By sunset, when the waters began to finally recede the rebel nation of Aceh, that had faced the hardships of generations of civil war, was diminished beyond recognition.

Villages lost 30%, 50%, 70%, 90% of their citizens. But it would be a long time before they would know the extent of their loss. On the eve of Dec. 26^th, 2004 the survivors were thirsty. They were looking for their children, their spouses, their mothers and fathers. They were naked, but for the mud. They were itchy. The night was coming and they wondered; would there be more waves?

Beginning in the first few weeks of the aftermath of the Tsunami, Bumi Sehat has maintained a clinic for the survivors. We came to Samatiga with a team from IDEP and WALHI foundations. We stretched tarps over bamboo and began to see patients. We worked with our sister NGOs to establish water supply, dig pit toilets, usurp tents for people living in the open, some of Team Bumi, my own grown children, recovered bodies.

Today in the 4^th year of what we hopefully call “recovery” and pray is truly “healing,” Bumi Sehat maintains and operates a beautiful proper free clinic for the people of Aceh. The beautiful land a gift from “Paula”, the clinic facility built and furnished by the generosity of Rotary S.E. Asia and Ubud, and currently maintained with operational funds from Direct Relief International plus generous help from smaller donors, friends and family all over the world, is busy and lively and lit with the warm dependable power of the sun, (thank you solar energy).

For the first two years following the Tsunami I spent more time in Aceh than I did at home with my family. Team Bumi Sehat Bali galvanized itself to maintain it’s beautiful growing services in Bali, while logistically supporting their team members going to the dangerous geologically and politically unstable disaster zone, that had once been the proud, jeweled coastline of Aceh. It was a hard time of desperately treating Tsunami wounds that would not heal. We fought a war with malaria, dengue fever, unidentified skin conditions unique to the thousands of patients we saw, who had been swept away in the violent stinking Tsunami water. We delivered babies, because that is What Bumi Sehat does best.

Slowly over the months and years we moved from tents and tarp clinic to a rumbia roofed hut with four rooms, built by the IDEP/WALHI team from trees felled by the Tsunami. Eventually IDEP found funding to build us a wooden clinic in Gampong Cot, in view of the sea, very close to the epicenter of the disaster. Finally Dear “Paula” purchased enough land for Bumi Sehat, and the Rotary brought in the miracle, a proper earthquake resistant clinic. Over 12,000 grieving Tsunami survivors live within walking distance of Bumi Sehat’s clinic, many more borrow vehicles and come in groups from great distances, traveling hours, seeking kind, clean, free, conscientious medical care. Dr. Eman, Nurses Liman and Bankit, Midwives Mega, Liza and Sumi, supported by a beautiful team, live and work on site, contributing significantly to the healing of Aceh.

When the small propeller plane my husband Wil and I take to come “home” to Aceh lands on the Meulaboh airstrip, I choke back tears. Ijal and Eti, faithful team members who themselves survived the Tsunami, are waiting. “Ibu Robin, a mother in labor is waiting for you at the clinic.”

We travel over a road that was once a moonscape and wonder at how smooth it has become, thanks to International Aid. The trip back to the clinic was once 2½ to 3 hours, today we arrive in 45 minutes. Meliza is in labor with her first child. By dinnertime she has had a lovely waterbirth. The smiling midwives, working with traditional midwife Ibu Juariah, settle Miliza and her tiny baby daughter into a clean bed to breastfeed. The extended family will spend the night. Our cooks bring plates filled to feed them all.

That evening, over simple spicy rice and fish dinner, the staff speaks of how the conflict in Aceh has settled since the peace treaty in 2006. There is no sound of gunfire in the distance, yet there have been “incidents” recently, reminders that war is always a threat the Acehnese live with. Thunder rolls in and it begins to rain as it can only rain in Sumatra, huge rain with drops the size of pennies. Even the clinic ducks are running for cover.

By 2 a.m. we midwives are called out to the village of Pinem. Ibu Asya is the traditional village midwife in attendance. She is worried as Ita Ristani, having her 5^th baby at home is not doing so well. Something feels wrong.

I know she will not stay with us long. I lay down beside Ita, with the baby between us. An hour and 47 minutes after her birth, Ita tells me, “Ibu Robin, Fitri is cold.” I listen, there is no longer a heartbeat. We cry together as the sun rises, it is so pink and purple, we all feel bruised by this morning.

The Bumi midwives recognize this mom and hope that her due dates were wrong, as she would be having this child 9 weeks early. Ita’s other four children are hiding in the next room of the wooden house, dimly lit with a kerosene lantern, newspaper is stuffed in the cracks between boards to keep out the wind. Ita’s husband is walking in the yard, littered with trash, smoking a nipa cigarette.

Ita moans, with a whoosh a salty amniotic sea breaks loose and in that one push the tiny baby is washed out of her mother. It is too soon. I scoop her up and she cries weakly as I lay her on her mother’s now concave belly. This Baby’s tiny hands and feet have no creases, she is far too premature, Allah has not had time to draw the lines of her fate. We call the father and ask him to sing the prayer songs of Islam to his tiny daughter. He gives her the name, Fitri, her tiny heart is slowing. We gently explain this to the parents. I wonder, if this child had been born in a modern hospital with a neonatal unit, would she have a chance? My wondering can’t change the fact that we are here, in a wooden house, where the family will eat cold rice and dried fish in the morning. Transporting this baby to the hospital in Meulaboh would be of no use at all.

Ita tries to breastfeed but the baby who has no reflexes, we make a hot water bottle to keep Baby warm. I know she will not stay with us long. I lay down beside Ita, with the baby between us. An hour and 47 minutes after her birth, Ita tells me, “Ibu Robin, Fitri is cold.” I listen, there is no longer a heartbeat. We cry together as the sun rises, it is so pink and purple, we all feel bruised by this morning.

The day is filled with clinic duties. A man in his 80s has been picked up by our ambulance, he has been unable to eat for nearly three weeks without vomiting. He is dehydrated, Max our new medic volunteer from “Leap Now” puts in an IV line with Liman.

The ambulance also picks up a 17 year old girl, who looks like she is glowing with health, but she has had headaches and nausea and fainting spells. Her blood pressure jumps from 100/80 when she is conscious to 130/90 when she passes out, a mystery. We admit her.

3 a.m. March 5^th the midwives are called out by village midwife Sadhia. We arrive quickly at the home of Fitri, who has had prenatal care with us, and has attended the pregnancy education and exercise classes held weekly at Bumi Sehat.

Fitri lives in the concrete swamp getto that was once the fair city of Kuala Bubon. The little cement houses, built with relief funds, teeter on stilts, with rows of others, surrounded by the wetlands created by the Tsunami. Just at dawn a little daughter is born, robust and healthy. Allhamdullilah!

Saturday March 7^th – Yanti, the 17 year old patient, has another seizure. When conventional attempts to stop the convulsions were unsuccessful, we were able to stabilize the girl with acupuncture, thanks to hand phone contact with Dr. Bobbi in Bali, who guided us through the lifesaving procedure. Dr. Eman is very excited to witness natural medicine work in an emergency. In the late afternoon the eleven elder “Bidan Gampong”, village midwives, practicing in the area are gathered. Some came by foot, others rode with family by motorbike, some we picked up in the Bumi Automobile. Mimi, only days from her due date, has made them a noodle feast with vegetables from our garden, and the kitchen staff has made seaweed cakes. The women are excited. We open the meeting with prayers and gratitude. Stories unfold of how afraid these women have been. Some of them have been called too late, to find young mothers had died. These midwives have not been to school, they have no paper degrees, what they have is a lifetime of service and experience, and knowledge passed down from generations of baby-catching grandmothers. They are needed and trusted, honored in their communities for the spiritual authority to greet new life, they have the secret prayers. Typically the medical authorities disapprove of these traditional practitioners, and blame them when there is a birth tragedy. Until Bumi Sehat came to Samatiga, Aceh, they had no one to help them. Typically a Bidan Gampong is called early in labor, she stays quietly, squatting on her little wooden bench, chewing betel nut, gently massaging the laboring woman. When the baby comes she wipes the tiny face and helps the wee one to the breast. She will stay three days with the family, to cook and wash the laundry by hand and clean and look after the new mother and baby. If she does not stay, all the work may fall to the newly postpartum woman, this cannot be allowed. For this she is paid the equivalent of $1.50 to $3.00.

Two years ago a woman bled to death shortly after birthing her 4^th baby. Her husband had not called for help until it was too late. The traditional midwife arrived quickly, and the mother had lost consciousness. Having no phone she sent a neighbor boy on bicycle to Bumi Sehat to get help.

Our ambulance arrived within minutes but the mother had perished. This death galvanized the Traditional Village Midwives to work closely with Bumi Sehat.

Today, due to the generosity of our donors, we have 11 members of “Ikatan Bidan Gampong Bumi Sehat, Aceh, Indonesia” (the Society of Bumi Sehat Village Midwives of Aceh, Indonesia). Each one of them has a hand phone (mobile phone), provided by Bumi Sehat, and has been taught how to use it. Monthly, Bumi Sehat provides their pulsa  phone minutes(credit for making calls on a mobile phone), so they can always call for help. We meet regularly for capacity building workshops in hemorrhage prevention and control, breastfeeding start-up, we share the art and science of midwifery together. About half of the laboring women come with their chosen Bidan Gampong to the Bumi Clinic to birth. The rest call us to assist in their births in the huts and houses.

Our Village Midwives have requested a few things from Bumi Sehat’s donors… They need reading glasses, flashlights, new stainless steel instruments and bowls and Newton scales to weigh the babies. And, they want t-shirts with the Bumi Logo that say; “Ikatan Bidan Gampong Bumi Sehat, Aceh, Indonesia”. I assured them that our donors would be proud to help out. As for me, I am in awe, this is perhaps our most astonishing program, to hold hands with these women is an honor. To have their trust is revolutionary and lifesaving.

I have meet with midwifery students sponsored by Bumi donors, Yenni and Dahlia, in 1½ years they will be finished with their studies. At that time they will join the Bumi Sehat midwifery team. We are so proud of them and of our donors for making these miracles of education for Tsumani survivors possible.

Fauzan, age 22, is from the devastated village of Kuala Bubon. He survived the Tsunami hanging on to the dream of becoming a school teacher. His father has suffered a stroke and can no longer support Fauzan’s education. Fauzan has been working as a raft fisherman while going to school. He has only 1½ years left to get his teaching degree. Hearing the story, our Leap Now volunteer, Max, has decided with his friends to sponsor Fauzan, so he will not drop out.

Bumi Sehat has been criticized for not having an “exit strategy” for the clinic in Aceh. To be honest, if we exit here, the people of Aceh will not be able to find adequate funding to keep this quality of health care going. Exiting would mean abandonment, the staff would disperse, as they would need to find paying work. The medicines would run out and the buildings would fall to ruin.

While meeting with our staff here in Aceh, they timidly asked if Bumi Sehat was planning to keep the clinic project alive, I told them, “Honestly, I don’t have an exit strategy.” translator Mimi and Dr. Eman burst into tears of joy. This team is amazing. Each visit to the sight is a delight, as the vegetable gardens are bigger and better. the fruit trees are growing, the buildings and vehicles are well maintained. The patients fill out evaluation forms, praising the services here.

Chemene of Flow Fund purchased more fruit trees and plants for the clinic, as did Wil and I. Nurse Liman spends his entire day off, working hard in the garden, with Adi planting and nurturing the flowers and trees. Imagine how happy it feels to wake at dawn to find my midwives planting vegetables with the drivers and the gardening team, I jumped up to join them! Each team member takes pride in every aspect of life here. The vision and mission; to serve as a healing team, providing hygienic, professional, loving, effective medical services, protect safe motherhood and significantly contribute to infant survival, while setting an example of environmental consciousness, in a land so ravaged by grief, is held in the hearts of every Bumi Sehat team member.

As I write this I must stop… to help a village midwife turn a breech baby. Success, the mother was crying, as she had been told at the hospital that she must have a cesarean birth. She left smiling, with Perfect Prenatal vitamins and a head-down baby – Allhumdulilah!

Mimi, our dear translator spent three days and nights in labor. Another mom comes in and has her second baby very quickly. Her first had been born at Bumi Sehat in the early days following the Tsunami, when our clinic was but a shack.

Finally Mimi’s courage and determination pay off, she and Liman have a beautiful daughter born at Bumi Sehat. They named her Talitha Nadif Halilah Wijaya. I felt like my time in Aceh was complete… I had delivered the baby of my loyal staff, this baby is like a granddaughter to me.

The day and night of the Full Moon in March 2009 brought 8 new babies into the world at Bumi Sehat Bali! We are busy indeed. In early January two Bumi Sehat families who had lost children, just the previous year, due to birth defects, had perfectly healthy babies, born on the same day. How they celebrated together with smiles and hugs!

I must tell you all the story of Ibu Yudi and Pak Mulyono, they married across religions, Christian and Muslim, so their families have rejected them. We met them struggling with one child and pregnant with twins.

We were told there that she had sold the baby to another island. The nurse said, “You are poor and stupid, best we found a rich family to take that baby. Your kind will just make more anyway.” Pak Mulyono was in shock, “What can I do, go home and tell my wife I lost her baby, because I am poor?” he sobbed.

Each Christmas my husband Wil and I bring a carload of food to the slums in Sanur. This helps the Christians there, refugees from hard lives on other islands, have food to celebrate their own holiday. This December, while delivering the food and gifts we saw Mulyono, looking very sad. “How are the babies?” I asked him. “Why did we not see you at Bumi Sehat?” He cried when he answered, “I have no motorbike, and no phone, the night Yudi went into labor I was too shy to wake the neighbors to ask to borrow their hand phone to get a ride to Bumi Sehat (it is quite far). So we walked in labor, (more than two kilometers) to a midwife. The babies were quickly born, two boys.” I hugged him in congratulations. “The story is not happy,” he continued, “The midwife charged us over 7,000,000 rupiah” (about US$640 – more than a year’s salary for Pak Mulyono. Had they called Bumi Sehat we would have picked them up in the van, and the birth services would have been free.) “We had no money to pay, our church gave the midwife 2½ million rupiah, but she said it was not enough (had they gone to an expensive hospital and had a cesarean birth, the price would have been less, this was extortion). She kept one of our babies, until I can pay off the balance.”

Wil and I immediately went with Pak Mulyono to the midwife’s practice. We were told there that she had sold the baby to another island. The nurse said, “You are poor and stupid, best we found a rich family to take that baby. Your kind will just make more anyway.” Pak Mulyono was in shock, “What can I do, go home and tell my wife I lost her baby, because I am poor?” he sobbed.

With the help of Raihan, an Acehnese friend who is familiar with human rights issues, we made contact with PBHI Legal Aid attorneys. Meanwhile the midwife appeared at Yudi and Mulyono’s shack with a corrupt policeman, threatening them. It was a three week long battle, complete with newspaper coverage in two languages. Two weeks after the New Year, the family was reunited with their baby. Because the boys are identical twins, the midwife was not able to steal another baby (oh yes – this does happen) and replace the child who by now had been separated from his parents for three months. This Baby, though thinner looks just like his twin brother.

This happy ending does not cancel the sad fact that all too often, families cannot take their babies home after birth, until they pay the bill in full. This is one good reason to have a project like Bumi Sehat. There are days and nights when it is just plain hard to do the work of Bumi Sehat; receiving the babies, helping the sick and injured, providing educations, navigating customs to bring in our vitamins, looking after recycling, education, and environmental projects, keeping a huge staff on two distant islands happy and well fed, and raising the funds to keep it all afloat… but this past Christmas Season, as we fought to reunite this family, it all came into focus for me. We are providing services so needed and appreciated. When I say “WE” I mean all of us, the midwives, nurses, doctors, housekeepers, cooks, gardeners, teachers, volunteers, administrators, drivers, and YES, donors. We hold hands to make miracles in health, education and environmental protection happen, day by day. If we make this world a little bit kinder, if we relieve just a wee bit of suffering, we have succeeded as a team.

I ask and I beg our donors & sponsors, you are our loving friends and family… to remain partners in this vision and mission. Please, stay with Team Bumi Sehat, we need you desperately to keep this work going, both in Bali and in Aceh.

In Gratitude…. Om Shanti, Allhumdulilah, Blessings…
Ibu Robin

How is Childbirth International involved?

Childbirth International has supported charitable groups working in developing countries since we were first founded 10 years ago.  Many of these groups operate without any government funding. We have provided scholarships for students in developing countries who are working with women and children from local villages. We are currently exploring ways that we can become more involved in the training and support of birth supporters in Indonesia and other countries in South East Asia. A number of Childbirth International students and graduates have spent time at Bumi Sehat as volunteers.

If you would like to learn more about Bumi Sehat and support them in their efforts, visit their website at www.bumisehat.org.

Previously we have looked at laying out of web pages to enhance their appeal. This is helpful if you have already made a start on your website or can pretty much find your way around the internet. What happens though when it seems more daunting than learning a new language? This week we will take a look at the commonly used terms and what it takes to get a website up and running.

URL – Uniform Resource Locator

The first thing you need for a website is an address – a unique location for people to be able to find you. The URL for Childbirth International is http://www.childbirthinternational.com. The URL is what people type in when they want to go to your website. The first part of the URL (http) defines the way your site works – the protocol used. You don’t need to worry about this. The second part (www.childbirthinternational.com) is the domain name. This is a name chosen by you. It is a good idea to choose something that defines your business as it is easier for people to remember and pass on to others. A domain name of www.ebd.com is not particularly memorable whereas www.eastbaydoulas.com is more likely to be remembered.

When you first start a website you can purchase the domain name from a company that makes them available. Sometimes a hosting company (see below) also offer this service. It costs around US$10-20 each year to purchase a domain name. You will usually get a reminder from the company who you purchased your domain name from when it is due for renewal. If you do not renew the domain name within a specific time frame it then becomes available for others to purchase.

When choosing a domain name you will need to decide whether it ends with .com or an alternative such as .net, .org or .us.

ISP – Internet Service Provider

The ISP is the company who provide you with an internet service. They are the company that you pay to provide you with access to the internet.

Hosting Service

The hosting service is provided by a company. They are the company who are hosting, or looking after, your website for you. They have a bank of computers called servers that store peoples websites on them. A server is just like a desktop computer but it works a little differently. The hosting company charge you to store your website pages on their servers. When someone types in your domain name, the internet will locate the pages on the hosting companies server and display that page.

Hosting service prices vary a lot, depending on the service you are getting. They can be as little as US$25 a year, or run in to the thousands. When looking for a hosting service it is worth thinking about the support offered. When the server goes down (becomes unavailable) on a Friday evening, it can be incredibly frustrating if you have to wait until Monday morning before someone can help you. A hosting company who offer after hours service such as a 24 hour chat can be a lot more helpful.

Hosting services may include free software such as shopping carts or marketing tools as part of the package. They may also have design templates to help you build your website.

VPS – Virtual Private Server

This is a type of hosting provision. The cheapest form of hosting is on a shared server – you share the space with many other people. Everyone’s website is protected by passwords but the actual space on the server itself is shared. The space available for you to build your website is usually ample for a doula or childbirth educator website but the site may be a little slower. A virtual private server is also one where the server is shared, but you have a defined area on the server specified. The most expensive option is a Private Server where yours is the only site on that server. Large companies will often have their own server that they run themselves. This requires a fixed internet line that is open all the time so that people can access the information on your server.

How do you start?

It can be daunting to start building a website. Think about it as a step by step process:

1. Think of some possible domain names for your website
2. Check on a domain name providers website to see if they are available
3. Purchase the domain name you want
4. Choose a hosting service
5. Begin building your website pages
6. Upload your website pages to the server
7. Start receiving visitors to your website!

Once your website is up and running you will want to maximize the number of people visiting – the more visitors you get the more likely you are to benefit from finding clients! In the next issue we will look at how you get your website listed on the search engines and what you can do to increase the number of hits on your site.

How does Childbirth International training address this?

Every Childbirth International course provides a section on building your business. We look at topics such as marketing and advertising, planning for a successful business, and using a website. In the future we will also be offering advanced courses on successful birthing businesses, using the internet for research and using the internet for advertising and marketing.

For many women ultrasound is an inevitable, even welcome, part of their regular antenatal visits – a reassuring opportunity to see the baby, and to check that all is well. For doctors, ultrasound technology offers a non-invasive way to screen for abnormalities and detect problems at an early stage. It is estimated that over one billion dollars is spent annually in the U.S. for prenatal ultrasounds¹. Frequency of ultrasound tests has become a benchmark of “good prenatal care” and women who do not have access to this technology are increasingly considered deprived. In some European countries, codes of practice exist which recommend women be offered a certain number of scans – in Germany for example a minimum of two scans during pregnancy is now seen as a “right”.

Yet ultrasound screening is not without controversy. Both the safety of the ultrasound technology itself, as well as the usefulness of the information gleaned from it, continue to be the subject of heated debate. In this article we explore some of the current issues regarding the routine use of ultrasound during pregnancy and ask what you, as doulas and childbirth educators, can do to help your clients find their way through this technological maze.

Ultrasound on the increase

Evidence suggests that both the frequency with which women are being offered ultrasound testing, and the length of time their fetuses are being exposed to ultrasound, is on the increase. Especially in countries where private obstetric-led care in the norm, many women are being exposed to more and more ultrasound tests - women considered “low risk” may receive as many as eight or nine scans during a pregnancy.  Higher-intensity ultrasound scans, such as 3-D or 4-D color scans, previously only offered to those women whose earlier screening had revealed a problem, are now being given on request or even offered proactively by caregivers. Women who do not have these advanced level scans routinely may begin to feel they are “missing out” on something valuable.

… there is very little evidence that the information gained from early pregnancy ultrasound screening actually improves the eventual outcome of the pregnancy.

It seems that ultrasound is popular with parents – many look forward to their routine scans, perhaps bringing relatives such as grandparents to get their first glimpse of the baby. In the United States, non-medical facilities such as Fetal Fotos of Salt Lake City, Utah, are springing up to cater to this demand by providing parents with photographs and videos of the unborn infant as souvenirs.

What is Ultrasound?

Ultrasound technology was originally developed during the 1940′s and was used in industry (to detect flaws in metal) and in warfare (to detect enemy submarines). In the 1950′s it began to be applied in medical diagnostics as a tool to detect abdominal tumors, and later, as a means of detecting gross fetal abnormalities such as anencephaly. Since then, the technology has become more refined and is able to detect ever more subtle indications of fetal well-being.

The term “ultrasound” refers to the very high frequency sound waves produced by ultrasound transmitters or transducers. When these sound waves hit a dense mass, such as bone or tissue, they produce echoes, which bounce back to a receiver. This receiver then translates these echoes into a signal that can be converted into either sound (fetal heartbeat) or an image.

Ultrasound technology is used in a number of pieces of equipment – not only the familiar “scan” used in pregnancy, but also in Doptone equipment (used to detect the fetal heartbeat), and electronic fetal monitoring equipment used during labor.  A fairly recent innovation is the development of the vaginal probe used very early in pregnancy when the uterus is too low in the abdomen for a regular scan to be effective.

Why is Ultrasound used?

Ultrasound technology has many possible applications, including:

• Confirming pregnancy and checking for multiple pregnancies
• Estimating gestational age
• Checking fetal growth
• Checking indications of fetal well-being including blood flow to and from the placenta, and the amount of amniotic fluid present
• Investigating problems such as suspected spontaneous abortion (miscarriage), bleeding during pregnancy, or abnormalities of the placenta
• Screening for abnormalities such as spina bifida
• Confirming the position of the baby and assisting in procedures, which require the position of the baby to be known e.g. amniocentesis and external cephalic version

Is Ultrasound useful?

In evaluating the usefulness of ultrasound, there are two key issues. Firstly, how reliable is ultrasound as a means on diagnosing abnormalities, and secondly, what can be done with that data once it has been obtained?

Available evidence indicates that routine ultrasound testing during early pregnancy does have some benefits – improved estimation of gestational age, earlier detection of multiple pregnancy, and earlier detection of some forms of fetal abnormality. There is evidence to suggest that for many women, confirmation of fetal life at an early stage in pregnancy is reassuring and improves their confidence in the pregnancy.

Despite this, there is very little evidence that the information gained from early pregnancy ultrasound screening actually improves the eventual outcome of the pregnancy. For example, in the case of a suspected miscarriage, ultrasound can be used to quickly to detect whether or not the fetal heart is beating. While that information may be eagerly sought by a woman who believes she is about to miscarry, there is little evidence to suggest that having that information is clinically useful or will improve the outcome for the fetus one way or the other. The scan though cannot determine the risk of the baby dying at a later stage of pregnancy.

Screening for fetal abnormality is equally problematic. Screening for abnormalities such as spina bifida (neural tube defects) is most accurate when carried out between 11-14 weeks of pregnancy². However, this is simply a screening tool and cannot be used to diagnose the condition. The scan can have false positive results, which means that many women would go on to have further and more invasive testing such as amniocentesis to confirm the diagnosis. In the worst case scenario she might opt for an early termination, when in fact the pregnancy is normal. One UK study suggested that as many as 1 in 200 pregnancies terminated for major abnormalities could have been wrongly diagnosed³.  At the same time, there are many abnormalities that cannot be reliably detected on a scan – for example, cerebral palsy.

To know definitively whether or not the baby has a neural tube defect the mother can choose to have amniocentesis. This is not usually done until 15-18 weeks of pregnancy. By the time the mother receives the results she is often in her 20^th week and is then faced with the decision to terminate a pregnancy with an induction of labor if the test shows her baby to have spina bifida. While chorionic villus sampling (CVS) can be carried out earlier, it is not possible to diagnose spina bifida from this test. In addition, there are risks with amniocentesis. The test has an accuracy rate of 95% – amongst women with normal amniocentesis results, 2 out of 100 babies are still born with fetal abnormalities. There is also a risk of miscarriage (1 in 200-400 pregnancies) and uterine infection (1 in 1,000 pregnancies)⁴. The other concern with having ultrasound scans to detect abnormalities is that whilst the scan may identify a possible problem there is no way of determining the severity. Conditions such as spina bifida can result in varying degrees of disability⁵. Some children with this abnormality have complete paralysis whilst others may have limited mobility. Hydrocephalus is commonly found with spina bifida but can often be corrected by the use of a shunt at birth. Mental disability can occur, but many children with spina bifida have no mental disability, are well integrated into normal schools and have a high degree of independence.

Scans done in the first or second trimester are often used to estimate gestational birth weight and estimated due date. However, this in itself can be problematic. A scan carried out at 20 weeks to determine estimated due date, for example, has an error margin of +/- 11 days. When comparing the accuracy of ultrasound scanning with the mother’s estimate of what her baby would weigh, the scan was not any more accurate⁶. Scanning may also be used to determine fetal growth and the presence of fetal growth retardation. In this case the scan has an error margin of 10%. Since clinical decisions such as whether or not to induce a labor may be dependant on these results the implications of an inaccurate assessment is clearly important. Randomized controlled trials suggest that ultrasound scanning in late pregnancy is associated with a much higher level of intervention, including early admission to hospital, with no detectable improvement in fetal outcome³.

There is no doubt that in certain circumstances ultrasound technology can be an immensely useful tool. However, there remains a question as to whether ultrasound should be routinely offered to all women or only used in specific circumstances.

Is Ultrasound safe?

Nobody really knows and everyone has a different view. There has been surprisingly little research to identify whether or not ultrasound has any negative effect on fetal health or subsequent health in childhood or adult life.

A number of studies have suggested that ultrasound waves can have a damaging effect on living tissue. Studies on animals have demonstrated a number of such effects including nerve damage, and an increase in the rate of cell death.

In humans, studies have suggested a wide variety of possible problems related to exposure to ultrasound including premature ovulation, premature labor, and low birth weight⁷. Other studies have suggested long term effects include a possible relationship with childhood cancers especially leukemia, as well as delayed speech development and dyslexia. There is some evidence that as few as two ultrasounds could affect brain development. Research carried out in Sweden found a higher incidence of left-handedness in men who had been given two scans when they were fetuses. While being left handed is not a health concern, it does raise the question whether or not the ultrasound itself affects the structure and organization of the brain.

Unfortunately many of these trials have been too small or flawed in their methodology. None of the randomized controlled trials have been large enough to yield any firm data one way or the other. The fact is we simply do not know. One of the main problems for researchers is that ultrasound technology has not been around long enough for long term data to be collated. Record keeping is also a problematic area with no common standards for recording when and for how long women have been exposed to ultrasound in pregnancy.

In addition there are no international standards on how a scan should be carried out. Each caregiver has their own policies and practices in relation to the frequency with which they recommend scanning, variable time of exposure and different types and age of equipment affecting accuracy and level of exposure.

Helping clients make an informed choice

As with any intervention, ultrasound has both advantages and risks, which may not be easy to quantify. Each couple will have their own perspective on the potential benefits of having an ultrasound (peace of mind, early detection of abnormality, and so on) versus the potential risks (potential for harm to the unborn baby, danger of “false positive” or unclear results).

By the time you meet your clients they may be some way into their pregnancy and therefore already have had several ultrasounds – indeed they may not even see ultrasound screening as a choice to be made, since it has become such a common part of prenatal care.

You can talk to your clients about the benefits and disadvantages of ultrasound scans, helping them to explore why they are choosing to have the tests and what information are they looking for. Encourage them to ask their caregivers about the tests, the purpose and what will the results be used for. Working through potential scenarios of what they will do if the scan reveals a problem can be beneficial. Most people expect the scan to tell them that they are having a healthy baby and are reluctant to consider the possibilities of an abnormality. Discussing this though assists them in determining how they would feel about further testing and the potential consequences of a scan. You can also discuss the alternatives to ultrasound – other indicators such as abdominal palpation and fundal height measurements may meet their need of knowing the baby is growing well for example.

Ultrasound on the web

There are many excellent sources of information about ultrasound screening in pregnancy available on the web.

http://www.ob-ultrasound.net/news.html
Contains links to a number of recent news articles about ultrasound

http://www.ob-ultrasound.net/history.html
A history of the development of ultrasound technology

http://www.midirs.org/mshop/shprod.nsf/SHOPPRODUCTopenform&id=C15D688EC14544438025710F004AD1A3
MIDIRs informed choice series of leaflets for professionals includes one on ultrasound screening in pregnancy. You can receive the full set of leaflets sent to you via email in PDF format for a very low cost. There is also a set of the same titles available for parents.

References

1. Wagner, M. 1999. Ultrasound: More Harm than Good? Midwifery Today, 50.
2. Nicolaides, K.H., Sebire, N.J., & Snijders, R.J.M. The 11-14 week scan: Nuchal translucency thickness. The Fetal Medicine Centre. Retrieved September 21^st 2003, from http://www.fetalmedicine.com/11
   14scanbook/Chapter1/chap01-3.htm
3. Buckley, S. 2002. Ultrasound Scans: Cause for Concern. Nexus Magazine 9 (6).
4. University of Pennysylvania Health System. (2001). Amniocentesis. Retrieved September 22^nd 2003, from http://www.pennhealth.com/health_info/pregnancy/
   stayhealthy/articles/amnio.html
5. Foster, M.R. 2003. Spina Bifida. E-Medicine. Retirieved September 22^nd 2003, from http://www.emedicine.com/orthoped/topic557.htm
6. Baum, J.D., Gussman. D., & Wirth, J.C. III. 2002. Clinical and Patient Estimation of Fetal Weight vs. Ultrasound Estimation. Journal of Reproductive Medicine, 47(3),194-198.
7. Enkin, M. Keirse, M.J.N.C., Neilson, J., Crowther, C., Duley, L., Hodnett, E., et.al. (2000). A guide to effective care in pregnancy and childbirth (3^rd ed.). Oxford: Oxford University Press.

How does Childbirth International training address this?

All Childbirth International courses focus on evidence-based care and explore the evidence for common medical interventions.

All courses are provided through flexible learning, meaning you can study at home, in your own time. No need for workshops, travel or child care. When choosing a training program, consider whether you want to get through your training as quickly as possible in order to be certified, or if you want the most comprehensive training that will help you develop both professionally and personally.

Katie, this is a very common problem reported by new doulas and can be frustrating, especially when you are enthusiastic and keen to sign up new clients. Unfortunately, in the early days, it is often our very enthusiasm that stands in our way and can prevent us from coming across professionally.

The first step is to consider the purpose of these initial meetings. Do you see them as an opportunity to “sell” your services to your client, or as an opportunity to find out more about what they are looking for?

The second step is to consider your image and presentation. How are you coming across? Do you dress in a style appropriate for the client? Do you have a ready supply of materials such as business cards, booking forms and so on with you? Are you on time? Do you greet them with a smile and a confident handshake? Sometimes these simple things can go a long way towards creating a professional image.

Asking close friends and family for feedback can be helpful. The most important part of the process is to reflect on your communication skills. Many new doulas go through a phase of what we call “doula zeal”, where they are so excited about their new career and are reading and learning so much, that they can seem somewhat overbearing, wanting to rescue every women and prevent her from having negative experiences. In addition they are often very keen to list all the things they can “do” for their clients – massage, aromatherapy, relaxation, and so on – without considering what it is that their client really wants or needs.

One technique that can be helpful is to try and resist the temptation to give information before you have asked questions. Asking open questions which avoid yes or no responses and encourage the client to open up about their needs can be helpful. Open questions are those that encourage fuller responses – they often begin with words such as why, when, and how. For example, if the client asks, “So, what do doulas actually do?”, instead of launching into download mode and listing everything you are able to do, try to take a moment to reflect on what she is really asking. It might be helpful to ask her what she has heard or read already, or what she has been told by other people. What did she like about what she has read? What things concern her? What would she like a doula to do for her? Having this information will enable you to tailor your response more precisely towards her needs.

How does Childbirth International training address this?

Childbirth International believes the most important part of being a birth doula, a postpartum doula, a childbirth educator or a breastfeeding counselor, is communication. How well do you listen? How aware are you of your own body language? How easy is it for you to separate your own feelings and choices from those of your client? Do you struggle when a client makes choices that you feel are vastly different from the ones you would make?

Because of the importance of communication skills, and the enormous value in reflecting on our own experiences and “birthing beliefs”, we place a lot of emphasis on this in our courses.

All students completing a full certification program will cover communication skills. You will complete one paper that uses reflective practice – looking at an event in your life and examining what you felt you have learned from the experience. Your trainer will be there to support and guide you, helping you to develop communication skills that will truly make a difference to your clients.