 So, now it's my great pleasure to introduce our speaker, Catherine Bell. I know Catherine. Catherine is studying her PhD here in Canberra. She's trained as a doula and a breastfeeding educator and has much to learn about mothering as to be able to support others. She's a birth advocate and a consumer representative with a keen focus on communication. As the birth cartographer, she authored the birth map boldly going where no birth plan has gone before. She lives on Feral Farm in South Wales, Australia, with her husband and four homeschool children. In her spare time, who knows that she would have any, she's undertaking a PhD. So welcome, Catherine. I'm going to hand over the microphone to you and... Fabulous. Thank you so much. Thank you, Deb. Thank you everybody for coming. It's absolutely blowing me away to see many people here. It's wonderful. So today I'm going to introduce to you a concept of birth cartography, which all about facilitating communication for enhanced decision making. This is a concept that came about from my experiences as a mother and then a doula. And it all began with the approach to birth, this systemised approach that we have to birth where women are placed on a metaphorical conveyor belt. They will reprocess their options and information and they often don't realise that there are alternatives to this is playing out. In addition to this, birth also takes place within a culture taught that they don't matter. They might hear things like, leave your dignity at the door, all that matters is a healthy baby, there are no... just have the epidural. It's not a competition. And so they carry this sense with them into that maternity ward where the purpose is to get in there, get the baby out and move on. There's no sense of honour or act, which is what dignity actually means. So it really struck me odd we're asking women their respect at the door. The result of this is that power imbalance. This power lies with the care provider who becomes the authority. They're controlling the knowledge, they're controlling the time and they're carrying the weight of liability. The women take on this sense of the patient rather than someone with a sense of agency. In this agent state, otherwise referred to as a trance of acid in their dempsey. The mother and partner, when they enter the hospital, just do as they're told. They realise very heavily on the care provider to guide them and in us make the decisions for them because they don't know, won't know and they've got no sense of agency or power within that space. Because of that, with this medicalisation of birth in the 1980s, the birth plan was introduced. And the idea of the birth plan was that it would balance out this. It would bring into that space an ability to document what was happening for the woman and what was important to her and give a sense of confidence to both parties. But unfortunately, in the 40 years that the plan produced, what we've actually seen is a situation where you either love the birth plan or you hate the birth plan. And in some places, the birth plan is very problematic. In other places, it's a little bit more accepted. And quite able across the world. Generally, the problems with the birth plan are around the lack of communication. Most women are creating their birth plans away from the care provider, using internet, using friendship groups, using resources outside of the care provider location. The first time the provider sees the plan is usually on the day of the birth. When things are happening and it's a little bit inconvenient to stop and read the plan. Because most women are birthing with continuity of care, they're attached to that relationship and have that ongoing conversation that actually makes a plan unnecessary because everybody knows where they're at. And on top of that, the word plan is to be able to. People hear the plan and they think it's fixed, it's immovable. It's regimented that we've got a one-track mind happening. And so it's often suggested that use wishes and preferences instead. And the one with this is that wishes and preferences, something that are easily dismissed. So it takes away the women's power because now we're saying, yes, yes, we like you, you've got to say, but it might not happen. So also tell them that they need to be flexible. And while being flexible seems like a sensible thing, in this context, flexible really means complot. Please do what you hold because this is a system approach to birth and we've got a process to hold. So because of this issue with the birth plan, I came up with a new concept called birth artography. And the first step of artography was to bring the partner its base. So instead of just the midwife and the woman in our state, we now bring the partner into this space. And then as a critical point, we bring them all together in communication. And by doing this, we're managing the women and their partners to involve their care provider in this process. An absence of continuity of care, which value is about 92% of women. This means that they have to be a very, very active player in this preparation process. So they need tools in order to start conversations with their providers that they can then document what has happened and ensure that that conversation is beyond with each next step by having those tools and bringing it all together. Kind of like they stand that they're birthing in the place for them. And if they find they're not in alignment with their chosen setting, hopefully they would have plenty of time to change. So this is a process that begins at the very beginning of process. Whereas with birth plans, they're often not even uttered until after 30 weeks pregnancy, which doesn't leave a lot of time if you've had a misalignment with your care provider. Another critical part of this process that we acknowledge that it's a woman-made process. The woman is the person who makes the decisions. All of these people come together to help her and support her. And the midwife provides you to her, but ultimately it's up to the woman's decisions and to own them. And this focus on informed decisions replaces this terminology of wishes and preference. But in women-informed decisions, other wishes and preferences, we give her her. We are not saying that this is something that's easily dismissed. We're acknowledging that this is indeed something solid. That is based on conviction and church and knowledge and understanding. And it is in that can be used to provide informed consent or indeed informed refusal. And all the people involved understand that it is informed. And so we can move currently knowing that we're not going to be viable for something. And the reason informed decisions are so important is because it's ninja information. The informed decision going to be up of the woman's previous understanding or experience. And if she's birthed before and it wasn't a good experience, that's going to influence how she feels about making decisions now. Likewise, if she had an excellent experience, that's going to influence her. If this is the first pregnancy of what she's seen on television. So pre-understanding is going to be very variable from one person to the next. Now that she's pregnant, she's going to be exposed to new information. And this is going to include the information needs, various some procedures that are conducted during the pregnancy decision. She's going to receive new information, which also includes those wonderful tidbits that everybody feels obliged to tell her now that they can see she's pregnant. So she's also going to be receiving advice when, whether this is good information or not is incredibly variable. And she'll also be seeking information actively, whether she's reading books or looking at websites or asking questions of her care provider. Then, of course, that all comes into play with her current circumstances. What are her finances? What are her relationship status, her religious status, cultural staff, her birth philosophy? Is she happy about the pregnancy? What are the circumstances around that pregnancy? All of these things come into play to inform her decision. And it's only up to her and it's going to be variable. There's no one way. And so this is where the birth map comes in. So we've changed the terminology to map because a map gives a visual of pathways and alternatives. So it gives this idea of flexibility without taking away the woman's power. And now we're using informed decisions rather than wishes and preferences. We're letting her know that these are points where you need to seriously consider what's happening because informed consent needs to be informed. It's not just about whether or not it feels good in the moment. Decisions made in advance are more likely to be informed decisions because they're made at a time of rational rather than in a moment where you're feeling very stressed or under pressure. So this particular image, you can find it on my website if you want to study it or share it. But I'm going to take you through it step by step. The most important part of the map is the direction. And this is determined by the woman. And the only way we can give her disability is by actually providing her with the questions to ask. This is where we get a little bit lost with birth planning or birth preparation is that we're often bombarding her with information without first establishing what she actually needs to know. And she doesn't know what she doesn't know. So by providing her with the questions, she's better able to make informed decisions. And that's where the book that I wrote comes in. It's all about the questions that I wish I'd known to ask that women in my mother's group said, I wish I'd been told to ask that. And so it ended up becoming a book worth of questions. So there's a lot of questions that need to be asked. The first of those questions begin with how labor is going to begin. So labor could be spontaneous induced or avoided. And each of these will lead to a different pathway with different options and different considerations. So let's look at the vaginal pathway to begin with. And here we're looking at the different stages of birth because then we're talking the same language. We're using the language that the care provider is likely to be working with and we can get on the same page. Most birth plans will focus on the first stage, particularly in terms of pain management. So I'll use the example of the epidural to work our way through the map. So with the epidural, if you are making a decision in the moment, you're obviously going, I want that epidural. Now I'm not feeling great and I know that the epidural can make me feel better because culturally, that's what we've been taught. It's not talked about in a negative way. But before you get that epidural, you have to listen to the spiel of the anesthesis because this is where informed consent comes in. And that spiel usually tells you things that are specific to the risks and benefits of the procedure. But what we know from women who have experienced physical birth trauma is that if they had been told that an epidural actually led to a risk of an assisted delivery, they may have thought about it differently, particularly if that information had been given to them during pregnancy when they would have had a better understanding of how things, one decision leads to another leads to another and what their alternatives might be. So for informed decision making, it's important to know the risks of the procedure but also what comes after that procedure and what the pathway will look like once you've had that particular procedure. So an epidural pathway usually leads to a second stage that is on your back as opposed to being upright or moving around or in a bath. So your second stage options will be impacted by what happens during first stage and what happens during first stage in a birth mapping process is based on an if this, then that set of decisions that are made in advance. So the women know exactly where they are and under what circumstances they're going to change track in which pathway they're going to choose. The third stage is one that does get a bit of time in a standard birth plan but usually to the level of we want delayed cord clamping and skin to skin but without specifying what that actually means. So for a woman who has specified delayed cord clamping, if she's in a birth location, the care provider may interpret that as three minutes but for her, that might mean 10 minutes an hour or don't cut the cord at all. So they need to be communicating exactly what they mean by that phrase in the same way that the care providers need to provide more information about the epidural in the context of birth. The woman needs to be able to communicate what she actually needs in the context of the whole picture and make sure everyone's on the same page. The third stage is going to be different depending on what's happened previously. Most women, particularly if it's their first birth, they get to this stage and they don't realise that there's going to be an injection given to expel the placenta and what that is and why it's happening and they don't realise that there's going to be a lot of action around them. The image they might have in their head is quite different to what's actually happening and then that can lead to that sense of trauma. So making sure they've got a realistic expectation helps to reduce that trauma, confusion or stress. If we have a look at the caesarean pathway, you'll see that I've broken it down into four different types of caesarean. And for women to be able to prepare properly, they need to see these different pathways and these nuances. So normally we will talk about planned C-section versus emergency C-section, planned being before labour and emergency after labour. But for birth preparation and for women's feeling of safety, they need a little bit more information than that. So the before labour, non-emergency caesarean is the planned C-section in its true sense. You've got time to talk to each of the care providers that is involved. You may even have the opportunity to have a maternal assistant caesarean. You will know if the baby's done well and will need separation from the mother. You'll know what the mother's condition is. There's a lot more time to fully understand what's going on and prepare for it. If it's an unwelcome caesarean, then there's more time to get their head around accepting what's going on and making it a really positive experience. The before labour emergency, however, is never going to be a primary pathway. It's always going to be a contingency. And this is when some medical emergency has arisen, perhaps preeclampsia. Things are happening very fast. It may even be the baby's coming too early. And this is the kind of scenario where we don't want to dwell on it too much, but it is good to have a back-up plan so that you know who your support people are and you've got a sense of what's going to happen in that scenario. Who will be involved? What will it look like? What kind of energy can you expect? Where will people be and who's going to be coming in? How many people? If you can understand what that might look like, it's not as stressful if it actually starts to happen. When we move into the labour types of caesarean, this is where I've based this breakdown on the work of Michelle O'Dent, who talks about the two-hour birthing pool test where if a woman has had two uninterrupted hours in a warm birthing pool to get into the groove of labour but has not made progress, statistically, she is likely to end up with an assisted delivery or an emergency C-section. And so he suggests that at that point, there's a decision point that a woman can make to either choose an augmented labour or an in-labour non-emergency caesarean. And he speaks of the difference being the amount of exposure for the baby to the drugs that are used for the augmentation and the time that that might take and the exhaustion that the woman might experience, that an in-labour non-emergency caesarean leads to a better recovery, quicker recovery. No one's exhausted, less likely to be separated. So when we take into consideration and weigh it up, the woman can determine which of those pathways feels better for her and whether she wants to perhaps try one pathway for a bit. And she knows when she can lead to her. If she's got a really clear picture of what those pathways look like and when she can change track, she knows where she is and she feels more powerful. She has that sense of agency. Then of course the in-labour emergency is again going to be only ever a contingency. This is the point where things are happening quite quickly and the outcomes may mean separation and it's quite a difficult post-birth time. And just having a backup ready for that scenario can make it very reassuring for parents. And if they understand what that might look like if the red button is pressed, what does that look like and why are things happening? They build a sense of trust in their care provider and that's very reassuring for both parents. Then the map comes back together again at the post-birth point where in those first few hours and days there are several standard procedures. Here in Australia it's hepatitis B, vitamin K and a heel prick test. In America we have the eye group it's different around the world but when women understand what those procedures are in advance and because they need to provide consent for them it's important that they are informed properly about what they are and why they're happening so that there's no confusion. And it's also useful at this point just to have a breastfeeding plan and this will be very dependent on what their breastfeeding goals are and they can understand how breastfeeding might be impacted by the different pathways that they've moved along and this can be a very, very positive experience for them to be able to reach their breastfeeding goals and know who their support people are and where to get that information. Those are the aspects that get documented into a written map that a document that gets passed on to the care provider and referred to during the birth. But birth cartography takes women a little bit further than that because we know that preparing for beyond the birth is very important. We need to align reality and expectation and ensure that women understand mattressence which I think is such a beautiful word and when you understand that it's not just a couple of days and then you're back on your feet that first year can be very full on for parents and the transition into parenting needs to be a team effort. And this is important for setting up support systems that help reduce that risk of postnatal depression for partners as well as mothers. And this is about understanding what your family and friends circle support might be but also what other support systems might be available within your community. And then we set up our parents for a much better start and which is obviously much better for babies as well. So what I've found anecdotally so far is that the benefits for women who undertake this process is that they have increased confidence which comes from better understanding of the system as well as the knowledge that they gain in preparation and it's improved communication. So that because they know the questions they want to ask they are able to guide those anti-natal discussions. So instead of answering the question a midwife might say, do you have any questions? And they'll be like, I don't know. They can say, yes, actually today I'd like to address these particular questions. And then from there they can make truly informed decisions and provide informed consent or refusal as necessary. I am seeing that this does seem to reduce their intervention, but when they do choose intervention they're doing it on their own terms and they come out the other side with a positive story. And that seems to be the really critical difference. We want to see women feeling wonderful after their birth and we do know that it's not necessarily the outcomes itself but how they felt during that experience that makes the big difference. And I'm seeing this difference in the partners as well. And this is where by involving the partner explicitly in that process, we see their confidence increase and they have a sense of direction because the map gives them an if this then that set of instructions. And they have a better communication with the care provider. They've built an understanding of the words that are going to be heard. They know what they mean and they know who's involved. They know where they are. And this reduces their feelings of trauma that might come from that watching something happen without any way of being a part of it or helping and not knowing what to do. So this shifts them from being a protector to a supporter. And the difference here is that a protector is usually a little bit afraid, they're on edge, they're perhaps like the caveman marching in front of the cave, waiting for the saber-toothed tiger. Everything's a danger. They're on high alert and they're oozing adrenaline which is not good for the birth space. When the birth mapping happens, they are informed and confident and they shift to this space of being a supporter. They're no longer afraid. They know who's who, they know what's what and they know what their role is. And that's a very powerful shift. But what I found surprisingly and wonderfully was the benefit to the care providers. Midwives were telling me, I wish more women would do it this way. This was so fabulous. I knew that they were informed. So the informed consent, I had confidence there. Those appointments were efficient and effective. She was asking the questions and I was able to answer them. I knew what she needed. She knew what we could provide. It was wonderful. And it was truly woman-centered care. Even when the appointments weren't with the same midwife, the team, the midwife team or the documentation that was put into her notes allowed the next care provider, care provider left off because the woman knew where she was and she knew where she was going. And so of course, this means less stress in that working environment. The partner is now an active and supported and informed member of that team. And we're all working together. So that was, to me, was when I said, I'm onto something here with the birth map. This is changing things really positively. And so the last slide comes up and we see that we're bringing everybody together in communication with a focus on informed decision-making. The whole team is now informed, supported and confident. And I'm very aware of them that we've had and I really appreciate all your patience and that you're all still here even with those technical glitches. And so that's the birth map where we boldly go where no birth plan has gone before. We're informed, supported and confident in a team environment. And I'm going to check to see what questions are coming and hopefully you can all still hear me and we're all gold. Thanks, Catherine. Second half the audio was much better. So it was worth you going out and coming back again. And thanks for really switching into a new way of thinking about this whole birth plan, which has been a bit of a thawing in the side for a long time with the way it's been received. So I love what you did with informed decisions rather than preferences. It really, and it kind of puts it in a legalistic framework which is much harder to submit, isn't it, than your wishes or preferences, as you said. We had lots of questions coming up and comments. So I'll open it up for questions. If you want to put up your hand, I can give you the mic or you can type your question in. It'd be good if some people do sort of speaking as well. So let's hear. Celine, do you want to take the mic and ask that question? So Celine's asked about what's the pressure to consent to the standardized protocols. So we all know hospitals usually run on protocols that are standard for most people. Have you got any comment to make on that, Catherine? What I've witnessed and certainly what I've experienced myself as a mum, when you are more confident and you express yourself confidently that ability to provide consent or indeed refusal, when you do so confidently, it seems to be easier for the care provider to accept. Your level of confidence and conviction seems to make a big difference. And I think that with this process, because the discussion starts at the beginning of pregnancy, if you're not in alignment with your care provider, if something is really important to you and your care provider because of policy or restriction or the culture in that particular location restricts you, you've got time to seek alternatives or to come to some sort of negotiation around that. And so it's about having a lot more time. And that seems to be the key to make sure that everybody feels empowered. Women gaining power doesn't mean the care provider losing power. It's a win-win-win scenario for everybody. And that's what I'm anecdotally witnessing, is that the key is in that confidence that the women feel. Does that answer the question? Thank you. I'm just going to phone Caroline McIntosh. I think she wanted to ask a question. So we have to give you the mic, Caroline. OK, can you see it there now? See the mic? No, you don't? I'm not sure what. They have to click on the blue phone and enable their microphone. Ah, OK. Can you see the blue phone? Because they came in with no mics, yeah. Right, yeah. Thank you, Lorraine. No blue phone either. Oh, no. I don't know how to do that. So do you want to type your question, Caroline? No, I'd love to hear your lovely, your lovely accent, though. Have you got a question you want to type? Maybe while Caroline's typing, there was something from Joe Carter earlier, Catherine, that asked, how do we get started? How do we do it? Well, the key part is that women actually have the questions, which is what I provide in my book. So the book is the tool that gets the conversation started. My website contains a lot of extra information for those that are keen to try and embed this into their processes. But it seems to me... What is your website, Catherine? I might put it up for you. Sorry. Yeah, bellabirth.org. I can type it in there as well. There we go. Yeah, that's it, yeah. Perfect. So on bellabirth.org, I've got a copy of the map explained there and details of how it all comes together and how you can embed it into your programs. But the critical part is that women have their side to play. And I liken it to building a bridge that happens, like the Sydney Harbour Bridge was built from both sides of the harbour and it needed two sides to come together and meet in the middle. If it's all clinical or all with women, they don't tend to meet. So birth plans tend to stay with the women and clinical policies stay over on the hospital side. What the birth map is aiming to do is bring those things together in a way where we can be truly woman-centered but realistic. If a woman is choosing to birth within a medical system, she needs to understand what that's actually going to look like and that it's not necessarily reasonable to expect that she's going to have a natural birth within that system. It's going to be very difficult. So if that's her goal, she needs to be able to prepare the best scenario to lead to that goal and also to be able to understand where she is on the map. So it's kind of like walking through a zoo where you see those, you are here dots on the map. You get an image in your head and you know where you are at each time. And if you want to see the gorillas, you know the pathway to the gorillas. But if the feeding time is already finished, that option is no longer available. You can work out how you're going to move through that particular landscape. And if you need to avoid the lions, then you can be better empowered to do that. And it reminds me of Joe Carter's question about the fragmented care where you only get that 10 minutes. That's where having those questions to ask, the women can make those appointments really efficient. And it's about the woman being able to work out exactly the questions she wants to ask so that she can make those appointments really efficient. And then between appointments, she can fill in the gaps. So that's what I'm seeing that this process does is it really brings the whole lot together and makes those 10 minutes really efficient. That's probably a good place to close that off, Catherine. It's 10-2 when we've got a few housekeepers to go through before we set up for the next one. But I want to thank you so much. I think these conferences are about stretching our minds and being introduced to innovative ideas. And you've done that for us today. And I want to thank you very, very much. So join me, everyone, in a virtual clap and a elbow bump. Yeah.