Katie Moriarty on the interplay with space and place during birth.

Editor’s Note: The opinions expressed in this blog post are solely those of the author.
Spoiler Alert: This post discusses events in Call the Midwife Season 7 Episode 5.

Flight takes many forms
It can be an unfolding of feathers – a soaring upward into light OR a departure—a running away
A retreat from pain towards a distant joy we cannot see through clouds
Flight can be such a very lonely enterprise

Episode five had several story lines—the topics explored were:

• Tocophobia—a fear of childbirth—I thought it was post-traumatic stress disorder (PTSD)
• Leprosy (they stated the current appropriate term is Hanson’s Disease).
• And the preparation of a community event—the Poplar Picnic

We saw Trixie go off to the Italian Riviera to ‘convalesce’ – I loved how Helen George (the actress that plays Trixie) disguised her pregnancy this season with coats, capes, shawls, purses and her birth bag, sitting and varied camera angles. And welcome back Barbara and Tom—just in the nick of time as the Nonnatus House midwives and nuns will need more help!

I wanted to write about the storyline of tocophobia—I had a birth that I attended many years ago and when I was watching this episode-I had a flashback to that birthing center and our birthing room! I believe this situation was more like a PTSD—but she had had a very traumatic first birth in a hospital with a physician and now with her second birth she wanted to be in a Freestanding Birth Center and she chose to be with a Certified Nurse-Midwife. During her prenatal appointments we had discussed how she envisioned this birth to be different and we thoroughly discussed her wants, desires, hopes through her birth plan. Our consulting physician met with her as well—and we also discussed reasons that we would need to transfer if there were any complications. This was her fear—she did not want to go to the hospital. I do remember spending a lot of time discussing how even if she had to be transferred that this was a different situation as she had providers that were listening to her.

When she was completed dilated she just kept stating “I cannot push—I just cannot do this.” Many hours went by and just like the Nonnatus house midwives—I called in my consulting doctor. He sat outside and had unbelievable patience and said—“everything is normal with the baby’s heart rate—we will just wait until her body does the work.” Nurse Anderson and Shelagh were saying the exact same words that I had said years ago! “I am here”, “Keep looking at me” “You are not alone—I can help you…” I remember just repeating to myself—trust in birth, trust in birth!

In the end, she did have a beautiful birth (but ohhhhh did it take soooo longggggggg!). But there are two things that seemed so important to me: having a good team approach with the consulting physician where we had mutual trust, and the importance of the interplay with space and place. There is a fabulous article by Hammond and her colleagues from Australia called "Space, place and the midwife: Exploring the relationship between the birth environment, neurobiology and midwifery practice." The authors discuss how it is possible that one of the mechanisms through which space and place influence midwives and their practice is the production and release of neurochemicals such as oxytocin, which can be triggered by experiences and perceptions of the physical environment.

The article discusses how the actual birth environment is not only a physical space but it is also a place invested with meaning and value and partially constructed by the thoughts, feelings, and responses of the people who interact with it. As many midwives practice in hospital environments in the USA, we often work in difficult environments that focus on medical technology with a clinical aesthetic and the socio-cultural discourse which is founded in a biomedical model of obstetric care. When or if the physical environment does not support the professional, psychological and social needs of the provider/midwife, then negative feelings and stress can be experienced as a result. Birth is an interplay of relationships where the environment can influence the midwife and the midwife can influence the environment. It is important the we are in an environment where we can give quality care — where we have the ability to be aware of our feelings, and we are able to process difficult situations. It is important to recognize the environment can impact and influence us. Attributes such as being warm, open, sensitive, receptive, and having the capacity to engage and build on relationships are essential elements to giving quality midwifery care. This ability to embody and engage like this can have long-term consequences for a woman and her experience of her childbirth experience.

The authors discuss how oxytocin is known to increase calm, buffer stress, and facilitate positive human relationships. The oxytocin system has been identified as particularly open to environmental influences and is dynamically and sometimes mutually engaged with systems that control perception, stress reduction, threat detection and reward pathways. This trigger and release of oxytocin can assist in the task of increasing trust, reducing fear and social anxiety and enhance the ability to read and understand the emotional cues of others. So we can see how the environment or the physical space can be one factor that can mediate the release of oxytocin—if a place is calm, warm, friendly and supportive it will facilitate oxytocin release whereas a place experienced as stressful, threatening or demanding triggers the release of our stress hormones (cortisol and catecholamines).

We have often heard of the fight or flight mechanism; however, there is also the calm and connection system and oxytocin plays a big part of the activation of this response. The authors suggest that in an environment that midwives experience as calm, non-threatening and supportive–may through the production and release of oxytocin, enhance their capacity to facilitate positive social relationships and provide emotionally sensitive care to childbearing women.

I love that the authors end with stating the birth environment is not just an envelope of inert space within which the physical act of birth occurs--but like all space and place, the birth environment is partly created by the thoughts, feelings and responses of those that interact with it! Both the midwife and the childbearing woman are active agents in its creation and maintenance. I felt connected to Nurse Anderson and Shelagh with the beautiful birth and the supportive loving hands that they welcomed that baby into this world.

Fear can keep us tethered
Terror can clip our wings
But trust eases pain
Hope can lighten the sky
Laughter makes us courageous
And what matters most is not whether we hide or fly or even where our journey takes us
But what guides us home and where we come to land

Reference:

Hammond, A., Foureur, M., Homer, C.S.E, & Davis, D. (2013). Space, place and the midwife:

Exploring the relationship between the birth environment, neurobiology and midwifery

practice. Women and Birth, 26, 277-281.

Katie Moriarty, PhD, CNM, CAFCI, FACNM, RN is a professor on faculty at Frontier Nursing University and a Certified Nurse-Midwife with WSUPG CNM Service at Hutzel Women’s Hospital in Detroit, Michigan. Katie serves on the Board of Directors for the American College of Nurse-Midwives as the Region IV Representative. Previously she was the Associate Director of the Nurse-Midwifery Education Program at the University of Michigan.
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