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The pregnant midwife: A personal reflection on having a baby as a midwife

I have always had a passion for matters around pregnancy, birth and babies. For years I have enjoyed being a midwife, clinically in research and in teaching. My passion started at around 4 years old when my brother was born. Mesmerized by a growing belly and the fact that another human was coming in to the world, I read my mother’s antenatal books from cover to cover. Having just experienced the birth of my own baby, I felt compelled to write my own reflections and experiences down….

Please note: For personal reasons I would request that close family members do not read any further.

*Long post alert*

What happens when the midwife has a baby? We are people just like any other having a baby…right?…probably. Did I know too much?…Did that affect my choices? did I have a better choice and/or experience because I had ‘insider knowledge’?… One thing is certain. Having a baby as a midwife was unique for me.

The stick turned blue

Yes, our little Autumn baby was planned….and thankfully, we had no trouble conceiving our little darling, who was due to arrive conveniently after I had  been awarded my PhD. But my period being late and the pregnancy tests showing up negative confused me. This was my first experience of feeling as though ‘I should have known better’! … Of course, though I knew that all I was looking for was a little Human chorionic gonadotropin (hCG), the cheap sticks I had bought clearly were not sensitive enough to detect it…it took a friend to prompt me to spend a bit of extra cash on the test. Of course a fancy pants digital stick did the trick….Silly me. The midwife should have known better (was one of my first thoughts… and a recurrent theme throughout my pregnancy)! The pressure was on!

Of course when the stick did officially ‘turn blue’ my heart jumped into my mouth, knowing that this was an ‘oh sh*t’ moment. No take backsies. Yet, I have no idea why I panicked …it was planned after all! Perhaps it was because..

  1. My parents would know for sure that I was sexually active (ridiculous I know…especially as my husband and I have been together 18 years)!
  2. I really would need to finish my PhD in time
  3. Life was about to change for ever
  4. I think this pregnancy is a good thing (probably)

My unicorn was on her way..

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Choosing my care givers

Unlike many women who my just meet the nearest or most convenient midwife. I had the luxury of knowing a myriad of great midwives who could provide great care for me and my baby. I also had the luxury of knowing how and who to ask directly for what I wanted. I felt spoilt. This felt like a luxury that many women don’t have…but it was also a perfectly reasonable thing to be able to do. I was able to chose a midwife who I knew was ‘on the same page’… and who would care for me continuously throughout…Do all women get this opportunity?

Pregnancy symptoms

For years I have been caring for women with ligament pain, pelvic pain, odd sensations and physical stresses and strains. Being pregnant myself meant that I could finally feel what I had been describing… ‘Ahh…that’s what hey mean by feeling a ‘twang”

One great benefit of being a pregnant midwife is also knowing what symptoms to worry about and what symptoms not to worry about. I imagine that this may have enabled me to experience somewhat less worry than others experiencing such things for the first time….In the beginning anyway!

To tell or not to tell…that is the question

Other than the midwives I knew, there were other care givers throughout my pregnancy who were meeting me for the first time. They all began with the usual spiel about risks/benefits/routine and procedure. The question is (or was).. do I let them go on talking like I know nothing.. or do I let them know that I am a midwife who is used to spouting this spiel myself.

In not telling them, I felt like a fraud.. Like I was making a fool of them… But in telling them of my profession, I felt as though I would be giving up my status as a ‘regular’ maternity service user. My cover would essentially be blown.

A desire for honesty got the better of me. I told all new care givers that I was a midwife. The following happened:

  1. Clinicians dropped any facade of being ‘ultra professional’ – They became more friendly… like we were ‘on the same team’.
  2. I was told frequently ‘Well you know all of this already so I won’t repeat it’

As they did this, I felt a mix of emotions. On the one hand…I felt truly part of the team…a sense of power and autonomy…On the other hand… I felt like I no longer had the safety net of being ‘nurtured’ through my pregnancy. Was I missing out?..I’m not sure. But I was no longer treated as a ‘regular pregnant woman’.

Choosing my own care pathways

In my experience as a midwife, I have seen how some professionals can dismiss the thoughts, feelings and desires of women wanting to make decisions in relation to their own care pathways. For more on this, please see Michelle Quashie @QuashieMichelle 

As such, I sometimes had to fight hard to make sure that the women in my care got what they wanted. I was expecting to have the same fight.

However, I found that once people realised that I was a midwife, they were more willing to trust that my own decisions were informed decisions. They seemed less intent on trying to persuade me one way or another. They seemed to respect and accept my choice more than I had seen some maternity staff respect the choices of other women.

For me this highlighted issues around respecting women’s choice. When do we feel that women can make their own choices without question?…and when do women’s choices cause clinicians concern?….

Whatever the opinion of others… I, as a midwife could seemingly make any choice I wanted with ease…. Is this the same for all? I think not.

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Birth choices

I have actually known what my own birth choice would be for a long time now. My main fear was that my choice would be made unavailable to me. Pre-conceptually I had consulted the obstetric team to discuss my birth choices…Would they be facilitated? because if not…did I really want to get pregnant in the first place?… the answer was ‘Let’s wait and see once you get pregnant’…Damn. I was really looking for a signed deal beforehand.

Once I became pregnant of course, they held all of the cards. I was pregnant…. trapped… The baby had to come out somehow, but I was beholden to them.. as they were the ones who would decide whether or not to facilitate my choice. This also altered the power balance and really made me feel vulnerable… at the mercy of those with the power to say yes or no. It was not a nice place to be.

My midwife, and my consultant midwife were 100% supportive of my decision, but they were not in a position to sign on the dotted line. I wanted a beautiful planned cesarean section. Something which goes against the grain for some.

When it came to meeting the consultant team, I was nervous about what they would ‘allow’. Now… I hate the word ‘allow‘ in maternity services, but this is how it felt. I was asking permission to have this… asking them to facilitate this. They had the power to say no. As a midwife, I believe I knew the right things to say to maximize my chances of them agreeing to my birth choice. I also had all of the up to date guidelines and research to back up my arguments should I need them. I was still nervously holding my breath.

There was some resistance, I had some extra appointments and some hoops to jump through, but with some firm words and some strong midwifery back up, I was able to get my birth choice ‘agreed’ or ‘allowed’.  Though the clinical reasons for my birth choice are too complex to explain here, it felt as though my decision making was not so trusted by other professionals in this case. I also had to repeatedly sit and listen to the list of risks involved, and be repeatedly asked if I had wanted to change my mind. Would this be the case if I had chosen a vaginal birth?

The sense of relief was immense…I could finally start to look forward to the birth and enjoy my pregnancy!

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Though this relief could have come much earlier for me… having the obstetric team on board pre-conceptually would have made my experience so much better!

What I really wanted to do was have my birth choice go unquestioned. I wanted to know all of the facts and then be trusted to make my own decision. Doesn’t every person want this?…

A “good birth” goes beyond having a healthy baby…

But I felt as though I may be denied my choice if it did not conform with what the health professional believed was the ‘right’ decision… This was utterly terrifying. The consequences of my choice being denied would literally mean that I would have less control over what would happen to my body. This was a horrifying thought. I would literally be forced to have a vaginal birth against my will. This is literally how the reality  felt.

For more information around birth rights see: @birthrightsorg

These experiences in relation to birth choices got me thinking about ‘informed’ choice in maternity care…

Everyone is ever so concerned about gaining ‘informed’ consent (and rightly so)… but is it disconcerting that we forever talk about the risks of Cesarean section and rarely the benefits? Equally…do we (as healthcare professionals) inform women of the risks of a vaginal birth? or a hospital birth? Wouldn’t that be ‘true’ informed consent?

As a midwife, I have to admit that my favorite type of birth to be in attendance of is an uninterrupted home birth….they are fab!… but that is my preference as a midwife. My preference as a mother was a cesarean section, and I have to ensure that I remain objective in respect to all women’s choices regardless of these facts.

At the end of the day.. a baby is coming out of you. There are a variety of ways in which this can happen. Should there be a default or ‘preferred’ way? or is this ‘preferred’ way subjective to each and every woman? If so then we must stop talking about the ways in which we might prefer women to give birth…and instead celebrate women’s choice in pursuit of their own subjective ‘positive birth’.

See here about the myths associated with positive birth

In my case, I felt a solidarity with Helen George from Call the Midwife, who was shamed for choosing to have a cesarean section. I also identified with some of the reasons she gave for her very personal choice. Of course there are many other reasons why women may choose a cesarean section. Some have been explored in the following paper:

Why do women request an elective cesarean delivery for non-medical reasons? A systematic review of the qualitative literature

From my perspective…the ‘rights’ and ‘wrongs’ of one’s birth choices are too subjective to ever cast judgment upon.

Challenging poor practice

The care I received from the English maternity services in my area was fantastic….For the most part. Unfortunately I did encounter one incidence of poor practice. Sadly this episode warranted escalation.

As a midwife, I know my duty is to take further action (escalate) mistakes in practice where appropriate. However, as a mother, I was nervous about escalating the poor practice of someone whom I relied on for my care (and to facilitate my birth choices). Would they take revenge? would I loose my place of birth? or would my birth choices be taken from me?…It was a very vulnerable position to be in.

“After all…If you complain to the chef..they may spit in your food.”

Thankfully, with the support of my midwife, I am now working with the General Medical Council (GMC) to ensure that other mothers and babies can be protected from the same actions being repeated.

Aside from this… as a midwife, I feel highly privileged that I was able to spot this poor practice and call it out. Another pregnant woman (non-midwife) may not have spotted this poor practice, and been put at risk unknowingly. This highlights how vulnerable women may be, as they trust us all with their (and their babies) lives. Here the role of the midwife as an advocate becomes even more important for those who cannot always safeguard their own care.

Patient & Public Involvement in research

INVOLVE briefings state that there is an important distinction to be made between the perspectives of the public and the perspectives of people who have a professional role in health and social care services. As midwives are not considered to be patients under this guidance, I have felt unable to participate in Patient and Public Involvement (PPI) activities during my pregnancy. This was difficult, as I would have loved to have participated in PPI whilst pregnant in order to contribute to the improvement of maternity services from a user perspective. This issue is worthy of further discussion… after all, health professionals can be ‘patients’ too right?

Antenatal education

My husband is surely sick of my chums and I always talking pregnancy and birth…and of course passion for the profession can get a little sickly for some. So, I wanted the father of my baby to hear what I already knew from someone other than me. I didn’t want him to rely on me for information…after all, I may come across as a know it all rather than an equal partner in his parenting journey. So we went to NCT classes.

The classes were great and the information was sound….Yet, as a midwife… I could feel myself wanting to ‘approve’ of the information given out to the group.

During the challenges set out for us as a group, I was anxious. What if I got a question wrong? or stuck an anatomy sticker in the wrong place?

oh the shame!

Thankfully, I made no mistakes and my midwifery knowledge held strong. Yet again, I felt compelled to disclose my profession to the group. Not to do so felt dishonest somehow, like I was tricking them into thinking I was new to pregnancy and birth from all perspectives…and not just from a parental one. As such, I was relied upon at times for the lived experience of maternity services. People were also generally glad to have me on their ‘team’ during group challenges.

At the end of the course, I think my husband was glad to learn from someone perhaps more objective than myself. I also think that hearing the facts from another birth educator strengthened my husbands faith in what I had been saying all along…For example.. he now trusts that it is indeed OK to have a glass of wine whilst breastfeeding (Very important)!

And just like any other mum of course… I needed to meet other people sharing the same journey as I was.

And so little ‘Loveday Alice Pezaro’ came into the world. I had the perfect ‘positive’ birth (for me).. The breastfeeding is going wonderfully…and we are now knee deep in baby sensory groups and Costa Coffee chats. This experience from the other side of the fence has provided me with more empathy for women and more passion for womens rights in childbirth. The journey was less scary than I thought it might be. But…………………

What if I can’t breastfeed?

This was another real fear for me…having supported so many other women to breastfeed… what if I couldn’t do it myself? I mean… if the midwife can’t do it…What hope is there? 😮😨😩

These types of fears and anxieties resonate with other midwives who find themselves becoming mothers…In fact, the very pertinent research of my friend and mentor Dr. Sarah Church demonstrates how;

“a reliance on professional knowledge may create opportunities for choice and increased autonomy in some situations, although the need for intervention during childbirth, for example, may challenge the degree of autonomy exercised by midwives and the choices available to them. As knowledgeable experts, midwives demonstrate a very different understanding of risk and safety in relation to their own experiences of childbirth. Professional knowledge may increase their anxieties which may not be addressed appropriately by caregivers due to their professional status. The use of knowledge in this way highlights potential conflict between their position as midwives and their experience as mothers, illustrating that midwives’ ability to exercise agency and autonomy in relation to their pregnancy and childbirth experiences is potentially problematic.”

Final thoughts and reflections

  • Being pregnant as a midwife increased both my anxieties and my autonomy.
  • My professional knowledge impacted significantly upon my own perceptions around risk and safety in maternity
  • As a midwife I knew how to best ‘get’ my birth choices.
  • I felt vulnerable at times, especially in calling out poor practice.
  • I felt as though I was treated differently because of my professional background
  • The pressure to ‘get it right’ was always on.

In conclusion, the whole experience of childbearing was much better than I thought it would ever be. I feared much more than I needed to, and in retrospect, I had a wonderful experience. If only I could have anticipated such good outcomes in advance…the fear of the ‘worst’ happening may have never been an issue. One thing is for sure. My experience of being on the other side of the fence will enrich my midwifery practice forever.

On another note..There are so many wonderful midwives and initiatives out there making births better for women and their babies…There are not enough words to mention all of their wonderful work in this single blog. But I would urge further reading around the following groups:

@birthrightsorg

@MatExpBazaar

@NatMatVoicesorg

@BirthChoiceUK 

@birthpositive 

…and Many more (happy to add to this list if suggestions are given)!

My baby ❤️ ‘Loveday Alice’

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If you would like to follow the progress of my work going forward..

Follow me via @SallyPezaroThe Academic MidwifeThis blog

Until next time…Look after yourselves and each other 💚💙💜❤

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Exploring ‘obstetric violence’ and ‘birth rape’

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Recently, the wonderful Ibone Olza (Perinatal Psychiatrist and Childbirth Activist from Childbirth is Ours, Spain) contacted me about her work on obstetric violence, birth rape and professional trauma. After reading her papers and watching her present her work, I was compelled to document and reflect upon some of the issues raised, here.

The following points are made within the paper: Fernández, Ibone Olza. “PTSD and obstetric violence.” Midwifery today with international midwife 105 (2013): 48-9.

Birth trauma has been defined as “Actual or threatened injury or death to the mother or her baby” (Beck 2008). Yet such trauma lies in the eye of the beholder, therefore, any trauma experienced by either the mother, newborn or the birth attendant may be due to a subjective experience of stress which does not need to fit any particular criteria necessarily. This means that some traumatic events may be subjective in their nature, and as such, we cannot judge what may or may not cause another person trauma. It is a personal interpretation or perception.

A meta-ethnographic analysis of studies about women’s perceptions and experiences of a traumatic birth reported that women are often traumatized as a result of the actions or inactions of midwifery staff (Elmir et al. 2010). Whatever, such inactions or actions may be…women often use words such as ‘barbaric’, ‘intrusive’, ‘horrific’ and ‘degrading’ to describe their mistreatment (Thomson and Downe 2008).

For Hodges, drugging or cutting a pregnant woman with no medical indication is an act of violence, even when performed by a medical professional in a hospital. Inappropriate medical treatment is also clearly abusive, although few women are aware that this is deliberate mistreatment (Hodges 2009).

The term ‘birth rape’ has been used by women who feel that their bodies have been violated. Kitzinger highlighted that many women who have experienced a traumatic birth display similar symptoms to rape survivors (Kitzinger 2006). The video below explores these issues in greater detail, as we can hear the lovely  Ibone Olza  sharing this work.

 

One of the things I was most encouraged about, was that  Ibone Olza  considers the wellbeing of the midwifery staff in her work. Birth attendants are often also traumatized by these acts, and may feel powerless to intervene. In a recent study by Beck, 26% of obstetric nurses met all the diagnostic criteria for screening positive for PTSD due to exposure to their patients who were traumatized (Beck and Gable 2012). Being present at  abusive deliveries can magnify staffs’ exposure to birth trauma.

staff use phrases such as…

“the physician violated her”

“a perfect delivery turned violent”

“unnecessary roughness with her perineum”

“felt like an accomplice to a crime”

“I felt like I was watching a rape.”

….to describe the guilt that ensued when they felt like they had failed women or they did not speak up and challenge/question…

Article 51 establishes that: The following acts implemented by health personnel are considered acts of obstetric violence:

  1. Untimely and ineffective attention of obstetric emergencies
  2. Forcing the woman to give birth in a supine position, with legs raised, when the necessary means to perform a vertical delivery are available
  3. Impeding the early attachment of the child with his/her mother without a medical cause thus preventing the early attachment and blocking the possibility of holding, nursing or breastfeeding immediately after birth
  4. Altering the natural process of low-risk delivery by using acceleration
    techniques, without obtaining voluntary, expressed and informed consent of the woman
  5. Performing delivery via cesarean section, when natural childbirth is possible, without obtaining voluntary, expressed, and informed consent from the woman

(D’Gregorio 2010)

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Yet whilst people do bad things, it is important to remember that they are not necessarily bad people…

This work explains how professionals may exert obstetric violence due to:

  • Lack of technical skills to deal with emotional and sexual aspects of childbirth.
  • Unsolved trauma. The medicalization of childbirth produces more severe iatrogenic
    complications (Johanson, Newburn and Macfarlane 2002; Belghiti et al. 2011). If the
    professionals do not have a supportive space to reflect or to deal with this aspect of iatrogenic care, they may fall into a spiral of continuously increased medicalization as a defensive strategy. Childbirth is then perceived as a very dangerous event, “a bomb ready to explode,” without realizing that interventions cause more unnecessary interventions and pain.
  • Professional burnout in birth attendants will lead to increased dehumanized care and therefore never-ending figures of women experiencing childbirth as very traumatic.

..and so the challenge will be to identify and address these root causes to ensure that maternity staff are able to provide excellence in midwifery care. My work explores how we might support the psychological wellbeing of health care staff may increase levels of humanity and compassion in care. I hope to keep in touch with Ibone Olza and many others around the world who share the same passion for this work. Together we may collectively work towards a time where maternity workers are psychologically safer, and therefore better able to provide the excellence in care they strive to give.

If you would like to follow the progress of my work going forward..

Follow me via @SallyPezaroThe Academic MidwifeThis blog

Until next time…Look after yourselves and each other 💚💙💜❤

References and further reading

  • Soet JE, Brack GA, DiIorio C. Prevalence and predictors of women’s experience of psychological trauma during childbirth. Birth 2003 Mar;30(1):36-46.
  • Creedy DK, Shochet IM, Horsfall J. Childbirth and the development of acute trauma symptoms: incidence and contributing factors. Birth 2000 Jun;27(2):104-111.
  • Ayers S, Pickering AD. Do women get post traumatic stress disorder as a result of childbirth? A prospective study of incidence. Birth 2001 Jun;28(2):111-118.
  • Beck CT, Gable RK, Sakala C, Declercq ER. Post traumatic stress disorder in new mothers: results from a two stage U.S. national survey. Birth 2011 Sep;38(3):216-227.
  • Allen S. A qualitative analysis of the process, mediating variables and impact of traumatic childbirth. Journal of Reproductive and Infant Psychology 1998;16(2-3):107-131.
  • Beck CT, Watson S. Impact of birth trauma on breast-feeding: a tale of two pathways. Nurs Res 2008 Jul-Aug;57(4):228-236.
  • Beck CT. Post-traumatic stress disorder due to childbirth: the aftermath. Nurs Res 2004 Jul-Aug;53(4):216-224.
  • Beck CT. Birth trauma: in the eye of the beholder. Nurs Res 2004 Jan-Feb;53(1):28-35.
  • Ayers S. Delivery as a traumatic event: prevalence, risk factors, and treatment for postnatal posttraumatic stress disorder. Clin Obstet Gynecol 2004 Sep;47(3):552-567.
  • Olde E, van der Hart O, Kleber R, van Son M. Posttraumatic stress following childbirth: a review. Clin Psychol Rev 2006 Jan;26(1):1-16.
  • Elmir R, Schmied V, Wilkes L, Jackson D. Women’s perceptions and experiences of a traumatic birth: a meta-ethnography. J Adv Nurs 2010 Oct;66(10):2142-2153.
  • Nicholls K, Ayers S. Childbirth-related post-traumatic stress disorder in couples: a qualitative study. Br J Health Psychol 2007 Nov;12(Pt 4):491-509.
  • Ayers S. Thoughts and emotions during traumatic birth: a qualitative study. Birth 2007 Sep;34(3):253-263.
  • Thomson G, Downe S. Widening the trauma discourse: the link between childbirth and experiences of abuse. J Psychosom Obstet Gynaecol 2008 Dec;29(4):268-273.
  • Goldbort JG. Women’s lived experience of their unexpected birthing process. MCN Am J Matern Child Nurs 2009 Jan-Feb;34(1):57-62.
  • Sawyer A, Ayers S. Post-traumatic growth in women after childbirth. Psychol Health 2009 Apr;24(4):457-471.
  • Hodges S. Abuse in hospital-based birth settings? J Perinat Educ 2009 Fall;18(4):8-11.
  • Kitzinger S. Birth as rape: There must be an end to ‘just in case’ obstetrics. British Journal of Midwifery 2006;14(9):544-545.
  • Beck CT. The anniversary of birth trauma: failure to rescue. Nurs Res 2006 Nov-Dec;55(6):381-390.
  • Beck CT, Gable RK. A Mixed Methods Study of Secondary Traumatic Stress in Labor and Delivery Nurses. J Obstet Gynecol Neonatal Nurs 2012 Jul 12.
  • Perez D’Gregorio R. Obstetric violence: a new legal term introduced in Venezuela. Int J Gynaecol Obstet 2010 Dec;111(3):201-202.
  • Callister LC. Making meaning: women’s birth narratives. J Obstet Gynecol Neonatal Nurs 2004 Jul-Aug;33(4):508-518.
  • Johanson R, Newburn M, Macfarlane A. Has the medicalisation of childbirth gone too far? BMJ 2002 Apr 13;324(7342):892-895.
  • Belghiti J, Kayem G, Dupont C, Rudigoz RC, Bouvier-Colle MH, Deneux-Tharaux C. Oxytocin during labour and risk of severe postpartum haemorrhage: a population-based, cohort-nested case-control study. BMJ Open 2011 Dec 21;1(2):e000514.

 

 

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💚💜❤Preventing Birth Trauma at #artofbirth16💚💜❤

Recently, I was asked by Dr. Gloria Esegbona from the @art_of_birth to share some of my thoughts on birth trauma at the latest  summit at Kings College London. My first thought, as always was…. do you mean physical? or psychological?… I was assured that her latest event would be addressing both. Time to learn & grow 💚💜❤

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And so how can we as midwives prevent physical birth trauma?

“we can reduce ventouse to and with left lateral & slow head delivery

“Preventable physical to & caused by poor positions and outdated pushing practices

Quiz – Which methods of pushing during vaginal delivery and pelvic floor relate to which perineal outcomes?

(No peeking at the link to get the answers first!)

#Discuss #GetYourGeekOn

Methods:
-open-glottis technique?
-Valsalva pushing?
———————-
Outcomes:
-incidence of instrumental and cesarean delivery?
-incidence of postpartum hemorrhage?
-urinary incontinence
-Episiotomy rates?
-maternal satisfaction?
-fetal heart rate (FHR) abnormalities?
-Apgar score?

No peeking at the answers link before you comment/answer below!

(We are still awaiting more evidence in any case)!

The Art of Birth is promoting art in the science of to prevent #birthtrauma 

And so what about the psychological trauma and the 2nd victim…the midwife?

Can we begin to understand women’s experiences in relation to psychological birth trauma? How do we revisit the language we use during birth? Can we all be more compassionate in our practice?

I was quoted on this day when talking about “superhero midwives” – healthy, well-supported lead to healthy, well-supported mums. …It is true…so many people wanting to do good….some burning out. Some traumatised.

I thank you all for hearing about my work on the wellbeing of midwives in the workplace.

I had some really great panel questions too…What I loved most about this conference was that I managed to receive lots of  and create  with so many inspiring midwives, doulas, students and others wanting to support each other, share and learn  💚💜❤.. I can’t wait to see some of you in the near future and learn more about how you have turned these lessons into practice. 💚💜❤

Until next time – look after yourselves and each other #GetYourGeekOn 💚💜❤